NEVADA GAMING COMMISSION NGC-14 (10/17/11) Restricted Licensee Report of Quarterly State License Fees Restricted Slot Machines Only - 1 through 15 slot machines 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: INSTRUCTIONS This report must be filed and fees must be paid PRIOR to placing slot machines into operation. If slot machines are to be added AFTER the beginning of a calendar quarter, you must file a supplemental FORM NGC-14. 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. Report all slot machines, pinball machines, video machines, and similar devices by denomination. Report slot machines and devices with denominations greater than one doller ($) under "Other." If slot machines are added during a quarter, the amount due is the difference between the amount previously paid and the total amount due based on the total number of slot machines after such addition. NOTE: The annual slot machine tax will also apply to additions, and a Form NGC-04 must be filed and taxes paid. If you have any questions, please contact the State Gaming Control Board, Tax and License Division. FEE SCHEDULE Total Number of Machines to Be Operated Amount Due 1................... $ 81 2................... $ 162 3................... $ 243 4................... $ 324 5................... $ 405 Total Number of Machines to Be Operated Amount Due 6.................... $ 546 7.................... $ 687 8.................... $ 828 9.................... $ 969 10.................... $ 1110 Total Number of Machines to Be Operated Amount Due 11................... $ 1251 12................... $ 1392 13................... $ 1533 14................... $ 1674 15................... $ 1815 QUARTERLY RENEWAL: This area only for machines to be operated during the forthcoming calendar quarter. Enter the total number of machines to be operated by denomination in the SLOT MACHINE SUMMARY box below. Denomination 1¢ 5¢ 10¢ 25¢ 50¢ $1 Quantity SLOT MACHINE SUMMARY Multi-Denom Other Total Slots 0 ADDITIONS DURING THE QUARTER: This area only for adding machines during a current calendar quarter. Enter the number of machines to be ADDED by denomination in the SLOT MACHINE SUMMARY box below. For Additions During the Quarter enter the following: Total Slots Licensed before addition Date of Addition: Denomination 1¢ 5¢ 10¢ 25¢ 50¢ Quantity $1 SLOT MACHINE SUMMARY Multi-Denom Other Total Slots 0 Quarterly Renewal: Line 1. Fees due on the total number of slot machines shown under "Total Slots" Is NGC-14 Late? Line 2. $ Enter (Yes/No) Penalty for late payment NRS 463.270(5) ………………………………………………….. (25% of Line 1, but not less than $50)…………………… Line 3. Remittance Due (Total of Line 1 and Line 2)………………. …………………………………. $ Additions During Quarter: Line 4. Fees due based on total number of slot machines under "Total Slots": $ Is NGC-14 Late? Enter (Yes/No) Line 5. Penalty for late payment NRS 463.270(5) ……………………………….. (25% of Line 4, but not less than $50)…………………… Line 6. Remittance Due (Total of Line 4 and Line 5)………………………………….. $ Please make remittance payable to the: NEVADA GAMING COMMISSION and return to 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 (Owner, Partner, President, Treasurer, Other-describe) 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 Signed Person to contact regarding this report: Name: Phone: RETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS American LegalNet, Inc. www.FormsWorkFlow.com