FG-710-4 TERMINATION OF FOREIGN GAMING BEFORE THE NEVADA GAMING COMMISSION AND THE STATE GAMING CONTROL BOARD In the Matter of EXACT NAME OF NEVADA LICENSEE Foreign Gaming Operation Statement NAME OF FOREIGN GAMING OPERATION FOREIGN LOCATION ADDRESS (e.g., Tunica, Mississippi) TYPE OF GAMING (e.g., Casino, Riverboat) DATE 1. The Nevada Licensee State the Nevada licensees name and address. 2. Affiliated Companies State the name(s) and address(s) of any affiliated company, holding company, intermediary company or publicly traded corporation related to the Nevada licensee. 3. Foreign Gaming Operation Statement (a) Date foreign gaming participation terminated. Date. (b) Reason(s) for termination of foreign gaming participation. Describe in detail the reason(s) for terminating participation (e.g., property sold, agreement terminated, or no longer a Nevada licensee). The Nevada licensee shall keep the Boards Corporate Securities Division promptly informed of all actions taken by the foreign jurisdiction regarding the foreign gaming operation and all matters directly or indirectly related thereto. Nevada Licensee By: Manual Signature___ Typed Signature Title