GAMING CONTROL BOARD SUSPICIOUS WAGER REPORT NGC REGULATION 22.121 AND 5A.160 DATE OF INCIDENT: PART I - CASINO REPORTING INFORMATION 1. CASINO NAME 2. LICENSEE/LOCATION # PART II - SUSPECT INFORMATION (PERSON INVOLVED IN SUSPICIOUS WAGERING - IF AVAILABLE) 3. INDIVIDUAL'S LAST NAME: 6. DESCRIBE IDENTIFICATION CREDENTIAL: A. DRIVER'S LICENSE/STATE I.D. C. OTHER D. NUMBER: F. SOCIAL SECURITY NUMBER: PART III - PREPARER INFORMATION 7. LAST NAME 8. FIRST NAME 10. TITLE/POSITION: 11. WORK PHONE NUMBER (INCLUDE AREA CODE): 4. FIRST NAME: 5. MIDDLE INITIAL: B. PASSPORT E. ISSUING AUTHORITY: G. DATE OF BIRTH: 9. MIDDLE INITIAL 12. WORK CARD NUMBER/ISSUING AGENCY: PART IV - SUSPICIOUS WAGERING INFORMATION 13. EXPLANATION/DESCRIPTION OF KNOWN OR SUSPECTED VIOLATION OF NGC REGULATION 22.121 AND 5A.160. PROVIDE A CLEAR AND CONCISE ACCOUNT OF THE POSSIBLE VIOLATION OF NGC REGULATION 22.121 AND 5A.160. DESCRIBE IN DETAIL WHAT IS UNUSUAL, IRREGULAR OR SUSPICIOUS ABOUT THE ACTIVITY. THIS SECTION OF THE REPORT IS CRITICAL. THE CARE WITH WHICH IT IS WRITTEN MAY MAKE THE DIFFERENCE IN WHETHER OR NOT THE DESCRIBED SUSPICIOUS CONDUCT IS CLEARLY UNDERSTOOD. ___________________________ Signature ___________________ Date This report shall be filed no later than 7 calendar days after the initial detection by the licensee of facts that may constitute a basis for filing such a report. If no suspect was identified on the date of the detection of the incident requiring the filing, a licensee may delay filing a report for an additional 7 calendar days to identify a suspect. In no case shall reporting be delayed more than 14 calendar days after the date of initial detection of a reportable transaction. In situations involving violations that require immediate attention, the licensee shall immediately notify, by telephone, the Board in addition to timely filing a report. Submit original form to: GAMING CONTROL BOARD, ENFORCEMENT DIVISION, 555 EAST WASHINGTON AVENUE, SUITE 2600, LAS VEGAS, NEVADA 89101. ENF-26 (12/12) American LegalNet, Inc. www.FormsWorkFlow.com