COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar AFFIDAVIT OF FULL DISCLOSURE No. : Plaintiff(s) STATE OF -against- JUDICIAL SUBPOENA : ss. COUNTY OF : : , being first duly sworn, deposes and says, Applicant’s Name Defendant(s) That, except as reflected on an application filed with the State Gaming Control Board, : . . . . . he/she. is. or. will . . . the. sole. beneficial .owner. of. any .direct . or indirect interest in or to a licensed . . . . . . . . . . be . . . . . . . . . . . . . . . . . . . . . . . . . . gaming operation or any portion thereof for which he/she has made application to the State Gaming Control Board and Nevada Gaming Commission, to be licensed or found suitable to own; THE PEOPLE OF THE STATE OFhave been reported in writing to the State Gaming Control Board, That, except such as NEW YORK TO he/she has no agreements or understandings with any other person and no present intent to hold as agent, nominee or otherwise any direct or indirect interest whatsoever in or to the licensed gaming operation or any portion thereof for which he/she seeks licensing or a finding of suitability by the Nevada Gaming Commission; That, except such as have been reported in writing to the State Gaming Control Board, GREETINGS: no agreements or understandings with any other person and no present intent to he/she has transfer at any future time any interest whatsoever in or to the licensed gaming operation or any WE COMMAND YOU, that all business and excuses being laid aside, you and each Gaming portion thereof for which he/she seeks licensing or a finding of suitability by the Nevada of you attend before , the Honorable at the Court Commission; located at County of That,, except such dayhave been reported in , at as of writing to the State Gaming Controland at any recessed in room on the , 20 o'clock in the noon, Board, he/she has no agreementsgive evidence as a witness inotheraction on the no present intent to pay or understandings with any this person and part of the or adjourned date, to testify and any sums of money or give anything of value as, including but without limitation, a finder’s fee or commission to any person related to the acquisition or sale of any direct or indirect interest whatsoever in or to the licensed gaming operation or any portion thereof for which he/she seeks licensing or a finding of suitability by the Nevada Gaming Commission; Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose any funds used or towas issued for a any liabilities incurred$50 to be incurred by That behalf this subpoena be used, and maximum penalty of or and all damages sustained as a result him/her in the acquisition of any direct or indirect interest in or to a licensed gaming operation or of your failure to comply. any portion thereof for which he/she seeks licensing or a finding of suitability by the Nevada Gaming Commission were not provided to him/her nor made available to of the Justices of the Witness, Honorable , one him/her through the efforts of anyone not disclosed to the State Gaming Control Board; Court in County, day of , 20 That, except as reported in writing to the State Gaming Control Board, no other person has provided collateral for or guaranteed payment of any loans made to him/her related to his/her application for licensing or a finding of suitability by the Nevada Gaming Commission. (Attorney must sign above and type name below) Attorney(s) for Applicant’s Signature Name and location of casino SUBSCRIBED AND SWORN to before me this , of Notary Public Form 10 Affidavit of Full Disclosure (Rev. 05/04) day Office and P.O. Address . Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com