NEVADA GAMING COMMISSION NONRESTRICTED LICENSEES ONLY NGC-15 (Rev. 10-17-11) REPORT OF QUARTERLY STATE GAMING LICENSE FEES 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: SECTION I SECTION II QUARTERLY RENEWAL ADDITIONS DURING QUARTER FOR THE QUARTER BEGINNING: NRS 463.375 DATE OF ADDITION: NRS 463.383 NRS 463.375 A -- SLOT MACHINES # UNITS B -- GAMES NRS 463.383 For Additions During the Quarter enter the following: D. Total games licensed before addition This section for Quarterly Renewal Only # UNITS C--SLOT MACHINES # UNITS D -- GAMES # UNITS 1 Cent Craps 1 Cent Craps 5 Cent Roulette 5 Cent Roulette 10 Cent Twenty-One 10 Cent Twenty-One 25 Cent Wheel of Fortune 25 Cent Wheel of Fortune 50 Cent Mini-Baccarat 50 Cent Mini-Baccarat $1.00 Baccarat $1.00 Baccarat Megabucks Caribbean Stud Megabucks Carribean Stud $5.00 Let it Ride $5.00 $25.00 $25.00 Let it Ride Pai Gow $100.00 Pai Gow Pai Gow Poker $100.00 Pai Gow Poker $500.00 3-Card Poker $500.00 3-Card Poker Mobile Gaming Multi Denomination Keno Keno Bingo Mobile Gaming Multi Denomination Additional Denominations Race Book Additional Denomincations Race Book (Describe Below): Sports Pool OR (Describe Below): Sports Pool OR Bingo Parlay Cards Only Parlay Cards Only Other Games (Describe Below): A. TOTAL SLOTS B. TOTAL GAMES Other Games (Describe Below): C. TOTAL SLOTS D. TOTAL GAMES E. CARD GAMES ADDITIONS DURING QUARTER QUARTERLY RENEWAL or FOR THE QUARTER BEGINNING: DATE OF ADDITION: Other Card Games Poker TOTAL CARD GAMES NO FEES DUE ON CARD GAMES IN THIS SECTION -- NRS 463.383(5) Quarterly Renewal: F. Fees due on the total number of slot machines shown on Line A times $20.00…………………………………….. $ G. Fees due based on total number of games shown on Line B, (See fee schedule)……………………………………….… H. Total fees due for Quarterly Renewal (amount of Line F plus amount Line G)…………………………………………………………………………….. $ Additions During Quarter: I. Fees due on the total number of slot machines shown on Line c times $20.00…………………………………….. $ J. Fees due based on total number of games shown on Line D, (Calculate)…………………………………………………… K. Total fees due (amount of Line I plus amount Line J)…………………………………………………………………………….. L. Penalty for late payment (NRS 463.270 (5)); $ Enter number of days late: (1) Less than 10 days late: 25% of the amount due, but not less than $50.00 and not more than $1,000.00………. (2) 10 or more days late: 25% of the amount due, but not less than $50.00 and not more than $5,000.00…………. M. Total amount due ………………………………………………………………………………………………………………………. $ Please make remittance payable to: NEVADA GAMING COMMISSION and 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 to the (Owner, Partner, President, Treasurer, Other-describe) 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