STATE OF NEVADA GAMING CONTROL BOARD OFFICIAL USE ONLY CASE # CASE TYPE VOLUNTARY STATEMENT CONTINUATION DATE OCCURRED TIME OCCURRED ID # NAME: I HAVE REVIEWED THIS STATEMENT OF PAGE(S) AND BELIEVE IT TO BE TRUE AND ACCURATE TO THE BEST OF MY RECOLLECTION. SIGNATURE DATE WITNESS PAGE OF PAGES ENF-12A (REV. 12-11) THIS COMPLETED FORM IS THE PROPERTY OF THE STATE OF NEVADA GAMING CONTROL BOARD PURSUANT TO NRS 463.120, AND MAY NOT BE DISTRIBUTED WITHOUT THE PERMISSION OF THE NEVADA GAMING CONTROL BOARD, OR ITS AUTHORIZED AGENTS, OR BY ORDER OF A COURT OF COMPETENT JURISDICTION American LegalNet, Inc. www.FormsWorkFlow.com