Restricted Licensees Quarterly State License Fee Report {NGC-14}

NGC-14 (04-01-18) Please correct if in error Amount Due 81 $ 162 243 324 405 546 687 828 Quarterly Filing: Complete this area for machines to be operated during the forthcoming calendar quarter. Enter the total number of slot machines to be operated by denomination in the Slot Machine Summary box below. Additions during the Quarter: Complete this area for adding slot machines during a current quarter. Enter the number of slot machines to be added by denomination in the Slot Machine Summary box below. $0.01 $0.05 $0.10 $0.25 $0.50 Other Total Slots Line 1. (shown under "Total Slots" on the "Slot Machine Summary" ) Line 1a. $ Line 2. Line 2a. Line 2b. Line 2c. $ Line 3. Line 4. $ x-none I,x-none certify and declare under the penalties of perjury that I am the x-noneof the business named above; that this is a true, correct and complete report x-noneto the best of my knowledge, information, and belief; and that this application and report is made with the knowledge and x-noneDatedx-noneSignedx-noneName:x-nonePhone: x-none NEVADA GAMING COMMISSION x-noneRESTRICTED LICENSEES ONLY x-noneQUARTERLY STATE LICENSE FEE REPORT x-noneFor Calendar Quarter: x-noneFiling Deadline: x-noneFor Office Use Only x-noneAccount Number: x-noneCheck Number x-noneLegal Name: x-noneTrade Name: x-noneBatch Number x-noneAddress: x-noneCity, State, Zip: x-noneEntry Date x-nonePlease correct if in error x-noneInstructions x-noneA. This report must be filed and fees paid PRIOR to placing slot machines into operation (NRS 463.373). If slot machines are to be added after the x-none beginning of a calendar quarter, you must file a supplemental NGC-14. State law requires that a penalty will be charged for late payments. x-noneB. The total number of slot machines to be operated must be included on this report, regardless of ownership. x-noneC. Report all slot machines, pinball machines, video machines, and similar devices by denomination. x-noneD. Report slot machines and devices with denominations greater than $1.00 under "Other". x-noneE. If slot machines are added during a quarter, the amount due is the difference between the amount previously paid and the total amount due x-none based on the total number of slot machines after such addition. x-noneF. The annual slot machine tax will apply to additions, and a NGC-04 form must be filed and taxes paid. x-noneTotal Number of Slot Machines x-noneTotal Number of Slot Machines to be operated to be operated Amount due x-none1 x-none9 x-none969$ x-none2 x-none10 x-none1,110 x-none3 x-none11 x-none1,251 x-none4 x-none12 x-none1,392 x-none5 x-none13 x-none1,533 x-none6 x-none14 x-none1,674 x-none7 x-none15 x-none1,815 x-none8 x-noneSlot Machine Summary x-noneDenomination x-none$1.00 x-noneMulti-Denom x-noneQuantity x-noneIf you have any questions, please contact the Nevada Gaming Control Board, Tax and License Division. Quarterly Filing x-noneEnter the total number of slot machines to be operated x-noneTOTAL DUE ON ORGINAL FILING BEFORE PENALTY Amendments (for slot machine additions during the calendar quarter) x-noneA. Enter date of addition: x-noneEnter the number of slot machines licensed before this addition x-noneEnter the number of slot machines to be added on the above date x-noneTotal number of slot machines licensed after addition x-noneTOTAL DUE ON AMENDED FILING BEFORE PENALTY x-nonePenalty for late payment NRS 463.270 (5): Enter number of day(s) late: x-none(25% of the amount due, but not less than $50) x-noneTOTAL AMOUNT DUE [Total of lines 1a or 2c and 3] x-noneEffective November 1, 2016, pursuant to Nevada Gaming Commission Regulation 6.030, all Nevada Gaming licensees x-none(Owner, Partner, President, Treasurer, Other-describe) x-noneconsent of all other individuals licensed. x-nonemust report and pay their gaming taxes and fees, and all reports relating thereto, pursuant to an electronic transfer approved by x-nonethe Nevada Gaming Control Board. x-nonePerson to contact regarding this report: x-noneRETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS American LegalNet, Inc. www.FormsWorkFlow.com