Pari-Mutuel Wagering Tax {NGC-PMT-1}

NGC-PMT-1 (04-01-18) NOT LATER THAN preceding race day(s). Please correct if in error $ $ $ $ Line 1. $ Line 2. $ x-none I,x-none certify and declare under the penalties of perjury that I am the x-noneof the organization named above; that this is a true, correct and complete x-nonereport to the best of my knowledge, information, and belief.x-noneDatedx-noneSignedx-noneName:x-nonePhone: x-none NEVADA GAMING COMMISSION x-noneHORSE RACES AT COUNTY FAIRS x-nonePARI-MUTUEL WAGERING TAX x-noneThis report, with your remittance payable to the order of the NEVADA GAMING COMMISSION, is required to be filed x-nonecovering the 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-noneCovering the meets held on: x-nonePaid attendance x-noneTotal number of wagers x-noneTotal number of races x-noneTotal amount paid to winners x-noneAmount of breakage x-noneAmount of unpaid winners x-noneTotal dollar amount retained as commissions x-none(not to exceed 20% of total amount handled) x-noneTax Computation [NRS 466.125(2)] x-noneTotal amount of Pari-mutuel wagers x-noneTOTAL AMOUNT DUE [1% line 1] x-noneEffective November 1, 2016, pursuant to Nevada Gaming Commission Regulation 6.030, all Nevada Gaming licensees 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-noneRETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS x-nonePerson to contact regarding this report: American LegalNet, Inc. www.FormsWorkFlow.com