NGC-27 (08-23-11) NEVADA GAMING COMMISSION ANNUAL LICENSE FEE REPORT for the issuance or renewal of an Information Service License This report, together with your remittance payable to the order of the NEVADA GAMING COMMISSION, must be filed on or before December 31, for ensuing calendar year for licensee’s continuing operations (renewals). For Calendar Year Filing Deadline: For Office Use Only Account No., Name, Address, Zip Code Check Number Batch Number Entry Date Please correct if in error INSTRUCTIONS A. This form is for the use of operators of an information service ONLY. B. Annual fee for licensure as an information services operator is $6,000.00 per calendar year, pursuant to NRS Chapter 463.3856. C. Applicants for a new license must pay the full annual fee, without regard to the date of application or issuance of the license, prior to commencing operation. PLEASE COMPLETE THE FOLLOWING: 1. 2. Remittance due (Total of Line 1 and Line 2 above) 6,000.00 Penalty for late payment NRS 463.270(5) A. Less than 10 days late: $1,000.00 B. Ten or more days late: $1,500.00 3. $ Annual fee for license for operator of information service $ Please make remittance payable to: NEVADA GAMING COMMISSION Return to the State Gaming Control Board, PO Box 8004, Carson City, NV 89702-8004 Pursuant to NRS 353.1467, payments made to the State, in the aggregate, that amount to $10,000.00 or more must be sent electronically. I, , certify and declare under the penalties of perjury that I am the of the business named above; that this is a true, correct and complete report (Owner, Partner, President, Treasurer, Other-describe) to the best of my knowledge, information, and belief; and that this application and report is made with the knowledge and consent of all other individuals licensed. Dated Signed Person to contact regarding this report: Name: RETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS Phone: American LegalNet, Inc. www.FormsWorkFlow.com