Instructions And Summary Form For Paper Filers {NGC-36A}

NGC-36A (03-01-04) NEVADA GAMING COMMISSION Instructions and Summary Form for Paper Filers Period Covered: Filing Deadline: Account No., Name, Address, Zip Code For Office Use Only Batch Number Entry Date Please correct if in error General Instructions for attached supporting schedules: 1. When reporting for a location, please combine all contracts of the same type of agreement (space lease or participation) at that location into one entry. For example, if you have one space rental agreement for 3 machines and another space rental agreement for 7 machines at the same location, please combine the two agreements into one entry for 10 machines at that location. However, if you have one space rental agreement and one participation agreement at the same location, you must enter them separately on the NGC-36 form. 2. When entering information for each denomination, please break out information for .05, .25, and $1.00 machines only. All other denominations should be combined and listed under Other. 3. The initial pages of the supporting schedule contain locations where you are operating. Additional blank pages are provided for you to include new locations. Please use the correct GCB location number with the correct version number. Enter the location name and address on the supporting schedule as well. If you are not sure of the correct number, please contact the Tax and License Division. Due to the lead time required between printing and mailing, you may have ceased operations at one or more of the locations listed. Draw a line through these locations. Add any new locations where you have started operations after the printing of these forms. Make any other changes as necessary. 4. Be sure to include locations that were operated during any part of the reporting period. Indicate these partial operations by entering the number of days in the Days in operation column. 5. No entry may be left blank. Enter zero to indicate, for example, that no space lease rent was paid to the location. 6. Win is defined as drop less jackpots and regular machine fills. Do not deduct initial machine fills or any splits with the location for bucket sales. Bucket sales will be accounted for separately on your standard financial statement. 7. Additional column-by-column instructions are also available on our website. Please read them completely before completing the forms. I, , certify and declare under the penalties of perjury that I am the of the business named above; that this is a true, (Owner, Partner, President, Treasurer, Other-describe) 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 named on the gaming license. This certification applies to the NGC-36 report submitted. Dated Signed Person to contact regarding this report: Name: Phone: RETURN ORIGINAL AND MAKE A DUPLICATE FOR YOUR RECORDS