American LegalNet, Inc. www.FormsWorkFlow.com 14.180 APPLICATION Addendum MANUFACTURER YEAR DESCRIPTION SERIAL # MODEL # SELLER ID DENOM. CT PRICE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 (CT=Currency Type(F-T-U-M-O),TT=Transaction Type (S-L-V)) American LegalNet, Inc. www.FormsWorkFlow.com TT PURCHASER'S STATEMENT I, ______________________________, declare under penalty of perjury that each gaming device, as identified more fully on the attached Regulation 14.180 Application, will be used only for lawful purposes, specifically _________________________________________________ ___________________________________________________________ __________________________________________________________. (describe intended use) I acknowledge that all subsequent distribution of these devices must conform to all local, state, federal and foreign laws. _____________________________________________ Print Name _______________________________________ _________________ Signature of Purchaser Date American LegalNet, Inc. www.FormsWorkFlow.com Regulation 14.190 Approval to sell or dispose of gaming devices. A licensee, or entities other than a manufacturer and distributor, must request a written approval prior to the disposal or distribution of gaming devices. Additionally, a completed Regulation 14.180 Application Form must be submitted to the Enforcement Division. Instructions for Regulation 14.180 Application Form: The Regulation 14.180 Application Form must be completed in its entirety, with accurate and legible information, in order to complete gaming device transfers, sales and distributions, in accordance with Nevada Revised Statute 463.650 or NGCB Regulation 14.190. Revise or correct erroneous information. The Regulation 14.180 Application Form requires a separate page for the Purchaser's Statement, which must be submitted with each application. Include the specific use of the device(s) in the Statement; i.e., "resale in Arizona," or "home use in Arizona," etc. The three areas of the form inclusive of the "SELLER INFORMATION," "PURCHASER INFORMATION," and "DESTINATION INFORMATION" require specific details. While these areas are self-explanatory, special attention should be given to the final destination of the gaming devices, machine information and the type of transaction. The following examples are provided concerning the machine information section: CURRENCY TYPE (CT) field - located directly after the DENOMINATION field. This field is used to describe the type of currency that is accepted by the machine. Valid entries for the (CT) field are: "F" - Foreign currency/coin "T" - Tokens "U" - U.S. currency/coin "M" - Multiple "O" - Other TRANSACTION TYPE (TT) field - located directly after the PRICE field on the form. It explains that the price on the form is the value or the sales price of the device. There always must be an amount in the PRICE field, however, the DENOMINATION field may be blank. Valid entries for the (TT) field are: "S" - Sale - amount device sold for in PRICE field "L" - Leased machine - reflect value in PRICE field "V" - Value only - neither a sale nor lease; reflect value of device in the PRICE field, (i.e., giveaway or prize.) Inspection of devices may be done at any time and unannounced. The licensee/seller will be held solely responsible for ensuring the legality of the destination. Proof of the efforts made by the licensee/seller to ensure legality will be documented and maintained. Further questions regarding this matter should be directed to the Enforcement Division, at 555 East Washington Avenue, Suite 2600, Las Vegas, Nevada 89101. American LegalNet, Inc. www.FormsWorkFlow.com