Account No., Name, Address, Zip NEVADA GAMING CONTROL BOARD ER101 (11-5-92) For Office Use Only MONTHLY CONDENSED FINANCIAL STATEMENTS Batch No. Period Covered: Entry Date Filing Deadline: Please correct if in error INCOME STATEMENT 2 3 4 5 6 7 8 9 10 11 12 13 14 REFER TO ATTACHED INSTRUCTIONS BEFORE COMPLETING THIS FORM. OPERATING DEPARTMENTS TOTAL GAMING ROOMS FOOD BEVERAGE TOTAL SALES & OTHER REVENUE COST OF SALES GROSS MARGIN DEPARTMENTAL EXPENSES: Commissions Complimentary expenses Taxes & licenses Payroll taxes & benefits Payroll – officers & owners Payroll – other employees Other departmental expenses Total departmental expenses DEPARTMENTAL INCOME BALANCE SHEET 15 16 17 18 19 20 21 22 23 24 25 26 27 28 ASSETS: OTHER OPERATING EXPENSES Advertising, promotion Complimentary expenses Depreciation & amortization Employee benefits Other taxes & licenses Interest expense Music & entertainment expense Rent of premises Payroll taxes Payroll – officers & owners Payroll – other employees Misc. operating expenses TOTAL operating expenses OTHER DATA Cash on hand and Current assets in banks Fixed assets Other assets Casino receivables Current month Total Assets LIABILITIES & CAPITOL Current debt Prior month LONG -TERM DEBT: (a) Current portion Long-term debt Long-term portion Other debt Monthly debt serv. Total Liabilities DELINQUENT CURRENT LIABILITIES: (b) Net Capital Accts-pay-trade INCOME BEFORE INCOME TAXES TOTAL LIABILITIES (b) Accr’d payroll tax (b) 29 OTHER REVENUE Debt pymt in arrears (b) Other (a) Due within next 12 months (a) Over 60 days & CAPITAL I, certify and declare under the penalties of perjury that I am the (owner, president, treasurer, other) of the business named above; that this is a true, correct and complete report to the best of my knowledge, information, and belief; and that this report is made with the knowledge and consent of all other individuals licensed. Dated , 20 Signed Phone American LegalNet, Inc. www.FormsWorkflow.com