Annual License Fee Report For Manufacturers License {NGC-21M}

NGC-21M (04-01-18) Please correct if in error Line 1. $ Line 2. Line 3. $ 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-nonePerson to contact regarding this report: x-noneRETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS 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-nonePenalty for late payment ($250) NRS 463.270 (5) x-noneTOTAL AMOUNT DUE [Total of lines 1 and 2] x-noneEffective November 1, 2016, pursuant to Nevada Gaming Commission Regulation 6.030, all Nevada Gaming licensees x-noneC. For the issuance or renewal of a manufacturer's license the Nevada Gaming Commission shall charge and collect from x-none each applicant -- $1,000. x-noneIf you have any questions, please contact the Nevada Gaming Control Board, Tax and License Division. x-noneApplication for the issuance or renewal of a Manufacturer's License ($1,000) x-nonePlease correct if in error x-noneInstructions x-noneA. This form is for the use of MANUFACTURERS of GAMING DEVICES only (NRS 463.660). x-noneB. All licenses shall be issued for the calendar year beginning January 1 (and expiring December 31), and regardless x-none of the date of application or date of issuance of the license, the fees to be charged and collected under the provisions x-none of NRS 463.660 shall be those fees fixed as an annual license fee for manufacturers of gaming devices. x-noneCity, State, Zip: x-noneEntry Date x-noneTrade Name: x-noneBatch Number x-noneAddress: x-noneFor Office Use Only x-noneAccount Number: x-noneCheck Number x-noneLegal Name: x-none NEVADA GAMING COMMISSION x-noneANNUAL LICENSE FEE REPORT x-nonefor the issuance or renewal of a x-noneMANUFACTURER'S LICENSE x-noneThis report, with your remittance payable to the order of the NEVADA GAMING COMMISSION, is required to be filed PRIOR to the commencement of operations; and ON or BEFORE December 31 for the ensuing calendar year. x-noneFor Calendar Year: x-noneFiling Deadline: American LegalNet, Inc. www.FormsWorkFlow.com