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Total Actual Expenses for all sites SIGNATURE AND VERIFICATION Signature of top official or governing board member Signature of preparer Date PRINT name of preparer DAY TIME Phone Mail To Office of Attorney General Gaming Division 600 East Boulevard Avenue - Dept 125 Bismarck ND 58505-0040 SFN 9815 7-13 page 2 G- Total number of deals conducted Schedule B - Gaming Stamp Activity - All Sites Attach additional pages if necessary Schedule C - Eligible Use Contributions - Round all check amounts to nearest dollar Attach additional pages if necessary Check Number Recipient Rounded Check Amount Description of Use Code TOTAL Transfer total to Part III Line 25 of the tax return. NORTH DAKOTA GAMING TAX RETURN SHORT FORM OFFICE OF ATTORNEY GENERAL SFN 9815 7-2013 Quarter Ended A Gross Proceeds PART I - GAMING ACTIVITY B Prizes C Adj. Gross Proceeds D Cash Profit 1a* Bingo 1b. Quick Shot Bingo Card Marking Devices Raffles 3a* Pull Tabs - Jar Bar 3b. Pull Tabs - Dispensing Device 3c* Club Specials Tip Seal and Punch Boards 4a* Prize Boards Sports Pools Twenty-One Calcuttas 8a* Paddlewheels Poker 10. Other Interest /Cash Long /Tournament 11. Subtotal Remit to Office of Attorney General 12. Gaming Tax - Line 11 Column A multiplied by tax rate see instructions 13. Federal Excise Tax from Federal Form 730 - Attach Copies 14. TOTAL ADJUSTED GROSS PROCEEDS Line 11 column C less lines 12 and 13 PART II - ALLOWABLE EXPENSES AND NET PROCEEDS PART III - TRUST ACCOUNT 15. Allowable Expense - 22. Trust Carry-Over Prior Quarter Carry-Over 60 of Adjusted Gross Proceeds Line 14 16. Net Proceeds - Line 14 less line15 line 20 on last quarters return 18. Adjustment - Attach Explanation 19. Amount transferred to trust account this quarter Amount from line 19 Interest / Service Fees /Other 25. Eligible Use Contributions this quarter Total from Schedule C 26. Trust Account Carry-Over - Line 22 plus line 23 plus or less 24 less line 25 20. Net Proceeds Carry-Over - Line 16 plus line 17 plus or less line 18 less line 19 21. Gaming Account Check Register s Balance For Licensing Use Only 28. NORTH DAKOTA GAMING TAX RETURN SHORT FORM OFFICE OF ATTORNEY GENERAL SFN 9815 7-2013 Quarter Ended A Gross Proceeds PART I - GAMING ACTIVITY B Prizes C Adj. Gross Proceeds D Cash Profit 1a* Bingo 1b. Quick Shot Bingo Card Marking Devices Raffles 3a* Pull Tabs - Jar Bar 3b. Gross Proceeds D Cash Profit 1a* Bingo 1b. Quick Shot Bingo Card Marking Devices Raffles 3a* Pull Tabs - Jar Bar 3b. Pull Tabs - Dispensing Device 3c* Club Specials Tip Seal and Punch Boards 4a* Prize Boards Sports Pools Twenty-One Calcuttas 8a* Paddlewheels Poker 10. Pull Tabs - Dispensing Device 3c* Club Specials Tip Seal and Punch Boards 4a* Prize Boards Sports Pools Twenty-One Calcuttas 8a* Paddlewheels Poker 10. Other Interest /Cash Long /Tournament 11. Subtotal Remit to Office of Attorney General 12. Gaming Tax - Line 11 Column A multiplied by tax rate see instructions 13. Other Interest /Cash Long /Tournament 11. Subtotal Remit to Office of Attorney General 12. Gaming Tax - Line 11 Column A multiplied by tax rate see instructions 13. Federal Excise Tax from Federal Form 730 - Attach Copies 14. TOTAL ADJUSTED GROSS PROCEEDS Line 11 column C less lines 12 and 13 PART II - ALLOWABLE EXPENSES AND NET PROCEEDS PART III - TRUST ACCOUNT 15.

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