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Regulation 8.130 Supplemental Information Form - Nevada

Regulation 8.130 Supplemental Information Form Form. This is a Nevada form and can be used in Audit Division Nevada Gaming Commission And State Gaming Contol Board Statewide .
 Fillable pdf Last Modified 7/28/2009
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Regulation 8.130 Supplemental Information Form Licensee number Licensee name Transaction date and amount Lender name Lender address and phone number Federal tax identification number For all lenders except individuals, complete the next section, following the instructions below. For Corporations: List all corporate officers and include an address and social security number for each. Attach additional sheets as necessary. If the company is not publicly traded, include the information for all stockholders also. For Partnerships: List the requested information for all partners. For Trusts: Provide all requested information for the trustor and beneficiary. Also identify the applicable information for the trustee. Ownership Percentage Federal Tax ID Number Residential Address Name/Position Note: Use of the term "lender" does not preclude the use of this form in connection with other transactions described in Regulation 8.130. All lenders must fully describe the source of the funds used to make the loan to the licensee. If the funds were derived from business operations, identify the name, address and tax ID number of the business. Also include the name an address of the financial institution from which the funds were drawn, if applicable. You must also include the account number or other similar ID number. If the proceeds were drawn from savings and investments of the individual, identify the account information as described above. Additionally, describe briefly the source of those funds (e.g., employment, investments, etc.). If the source of the funds was a loan or similar contract with another entity, complete the "OTHER LENDERS" section. Revised 5/2009 American LegalNet, Inc. www.FormsWorkFlow.com Regulation 8.130 Supplemental Information Form Page 2 OTHER LENDERS (SEE INSTRUCTIONS ABOVE) Lender name Lender address and phone number Federal tax identification number OTHER LENDERS Officer, director, stockholder or partner information (see instructions for the primary lender at the beginning of thisform) Ownership Percentage Federal Tax ID Number Residential Address Name/Position SECURITY, COLLATERAL AND GUARANTIES If any form of security, collateral, or guaranty was obtained for the loan to the licensee or a loan to the entity making the loan to the licensee, name the guarantor and describe the arrangement. Guarantor's name and address Federal tax identification number Description of arrangement: For all guarantors except individuals, complete the schedule of principals below (see instructions for lenders at beginning of this form) Ownership Percentage Federal Tax ID Number Residential Address Name/Position NOTE: Copies of all executed agreements must be submitted with this form. If agreements are not written, please state this fact. Revised 5/2009 American LegalNet, Inc. www.FormsWorkFlow.com Regulation 8.130 Supplemental Information Form Page 3 Please fill in the following information in case questions arise regarding the information on this form. Person to contact/Position Company name Telephone number (include area code) I hereby authorize and request all brokerage firms, banks, savings and loans, or other financial institutions or officers of same, to permit duly appointed agents of the Nevada State Gaming Control Board to review and obtain copies of any and all documents, records or correspondence pertaining to persons identified in this document, including but not limited to past loan information, notes co-signed by individuals identified in this document, checking account records, savings deposit records, safe deposit records, passbook records, and general ledger folio sheets. Information provided by: ______________________________ Signature of lender or representative ______________________________ Name (print or type) ______________________________ Title _________________, State of_______ Subscribed and Sworn to me this______Day of_______20__ _______________________________ Notary Public in and for the County of Revised 5/2009 American LegalNet, Inc. www.FormsWorkFlow.com
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