NEVADA GAMING COMMISSION NGC-04 (09-08-11) Fiscal Year Report of Slot Machine Taxes Effective Date: Filing Deadline: Account No., Name, Address, Zip Code For Office Use Only Check Number Batch Number Entry Date Account No.: Legal Name: Trade Name: Address: City, State, Zip: Please correct if in error Please correct if in error Instructions This report must be filed and fees paid PRIOR to placing slot machines into operation. If slot machines are to be added AFTER the beginning of the fiscal year, you must file a supplemental NGC-04. A penalty will be charged for late filing. The total number of slot machines to be operated must be included on this report, regardless of ownership. This report must be filed and the prorated tax paid prior to the addition of slot machines during the fiscal year. If you have any questions, please contact the State Gaming Control Board, Tax and License Division. PRORATED TAX SCHEDULE Machines to Be Placed into Operation in the Month of July (7)..………………....…….….... August (8)…………....……..….….. September (9)……………......…… October (10)……...………….…….. November (11)………...………...... December (12)………...…...…..…. Line 1. Line 2. Amount Due for Each Machine $ 250.00 229.17 208.33 187.50 166.67 145.83 Machines to Be Placed into Operation in the Month of Amount Due for Each Machine January (1)………………….…....... February(2)………..….…….…...… March (3)………….…….……….… April (4)……………......…..….……. May (5)………………...…..…....….. June (6)……………...…..….….….. $ 125.00 104.17 83.33 62.50 41.67 20.83 Total number of slot machines to be operated: Tax due: (Use Prorated Tax Schedule for additions during the fiscal year, and enter date of addition) Line 3. $0.00 Penalty for late payment NRS 463.270(5): Enter number of days late: A. Less than 10 days late: 25% of the amount due, but not less than $50.00 and not more than $1000.00. B. Ten or more days late: 25% of the amount due, but not less than $50.00 and not more than $5000.00 Line 4. $0.00 $0.00 Total amount due: (Total of lines 2 and 3A or 3B) $0.00 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: Phone: RETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS American LegalNet, Inc. www.FormsWorkFlow.com