2015 - Disclosure Form MGC Vendors - Ver 2.0 Rev 2.25.15.pdf

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev 2.25.15 Page 1

DISCLOSURE FORM

FOR BACKGROUND INVESTIGATION OF MGC VENDOR

Name of Company:

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 2

INSTRUCTIONS FOR COMPLETING THIS DISCLOSURE FORM

It is the practice of the Massachusetts Gaming Commission (Commission) to require certain organizations with whom the Commission conducts business to complete this form as part of the background process.

1. COMPLETING THIS FORM:

A. Read each question carefully prior to answering. Answer every question completely and be sure not to leave blank spaces. If a question does not apply to you, indicate “Does Not Apply” or “N/A” in response to that question. If there is nothing to disclose in response to a particular question, state “None” in response to that question.

B. All required documentation must be submitted at the time of filing this form. You are under a continuing duty to notify the Commission within ten (10) days if there is a change of the information provided in this form to the Commission.

C. All authorizations and releases must be signed by an officer of the company.

D. The Statement of Truth form included with this form must be signed by an officer of the company.

E. The Release Authorization form included with this form must be notarized.

F. The signed Statement of Truth and the Release Authorization forms shall be submitted to the Commission in paper form.

2. FILING THE FORM WITH THE COMMISSION:

A complete form consists of this form and all exhibits. Once your form is accepted, it becomes the property of the

3. FINGERPRINTING:

Corporate officers, partners, and sole proprietors of the vendor are required to be fingerprinted in order to initiate a criminal records check. If the individual wishes to be fingerprinted by the Commission, please contact the Division of Licensing (617) 979-8400 to schedule an appointment for fingerprinting. If the individual must be fingerprinted in another state, he or she must request that the Commission mail out-of-state fingerprint cards and instructions.

4. CERTIFICATE OF GOOD STANDING:

If you have a business in Massachusetts or have ever conducted business in Massachusetts under the name of the company for which you are filing, you must submit a Certificate of Good Standing for that business. The link to the Certificate of Good Standing and its corresponding instructions is provided below.

https://wfb.dor.state.ma.us/webfile/Certificate/Public/WebForms/Welcome.aspx

5. IRS FORM 4506-T - REQUEST FOR TRANSCRIPT OF TAX RETURN:

Corporate officers, partners, and sole proprietors of the vendor are required to fill out an IRS Form 4506-T, a copy of which is attached to this Form. The 4506-T form must be sent directly to the IRS at the address indicated on the IRS 4506-T form. Line 5 of the 4506-T form must direct the IRS to send the transcript to: Massachusetts Gaming Commission, 100 Federal Street, 23rd floor, Boston, MA 02110, Attn: Investigations & Enforcement Bureau. A transcript for each of the past 4 years is required.

Initials/Date:

https://wfb.dor.state.ma.us/webfile/Certificate/Public/WebForms/Welcome.aspx

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 3

6. PUBLIC RECORDS LAW

The Massachusetts Public Records Law (Law), (http://www.sec.state.ma.us/pre/preidx.htm) found in Chapter 66, Section 10 of the Massachusetts General Laws, applies to records, applications, and documents made or received by a Massachusetts governmental entity including the Massachusetts Gaming Commission. Unless the requested records fall under an exemption to the Law, the responsive documents must be made available to the requester. A list of exemptions may be found in Chapter 4, Section 7(26) of the Massachusetts General Laws. Please note, the Commission will use its best efforts to protect any information it deems subject to an exemption. Final appeals are adjudicated by the Secretary of State.

Initials/Date:

http://www.sec.state.ma.us/pre/preidx.htm

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 4

PLEASE ANSWER THE FOLLOWING QUESTIONS IN THE SPACES PROVIDED

IF ANY ITEMS ARE NOT APPLICABLE, INDICATE “NOT APPLICABLE” or “N/A.”

DO NOT LEAVE ANY QUESTIONS UNANSWERED

NAME OF COMPANY:

(As it appears on the certificate of incorporation, charter, by-laws, partnership agreement, operating agreement, or other official documents)

D/B/A OR TRADE NAME(S):

BUSINESS WEBSITE:

FEDERAL IDENTIFICATION NUMBER (FIN):

MASSACHUSETTS TAXPAYER NUMBER:

DUN & BRADSTREET NUMBER (DUNS):

SOCIAL SECURITY NUMBER:

(For individual proprietorship only)

Initials/Date

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 5

CONTACT INFORMATION FOR LIAISON BETWEEN VENDOR AND GAMING COMMISSION

Last Name:

First Name: MI:

Title:

Business Name:

Business Address:

City: State: Zip Code:

Country: Province (if applicable):

Business Telephone: Extension:

Business Fax:

E-Mail Address:

Reason for filing this form:

PRINCIPAL BUSINESS ADDRESS

Number/Street:

City: State: Zip Code:

Country: Province (if applicable):

Business Telephone: Extension:

Business Fax:

BUSINESS ADDRESS FROM WHICH THE VENDOR IS OR WILL BE

CONDUCTING BUSINESS WITH COMMISSION

□Same as above

Number/Street:

City: State: Zip Code:

Country: Province (if applicable):

Business Telephone: Extension:

Business Fax:

Initials/Date____________________

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 6

PART 1 - CERTIFICATION

A. Is the company a minority-owned business that has been certified by either the Massachusetts Supplier Diversity Office or the Greater New England Minority Supplier Development Council, or both?

□ Yes - Provide Letter of Verification or Certification Number

NOTE: If providing a Letter of Verification, please label as attachment to question 1-A.

□ No

B. Is the company a woman-owned business that has been certified by either the Massachusetts Supplier Diversity Office, the Women’s Business Enterprise or National Council, or both?

□ Yes - Provide Letter of Verification or Certification Number

NOTE: If providing a Letter of Verification, please label as attachment to question 1-B.

C. Is the company a “veteran-owned small business” or a “service-disabled veteran-owned small business,” as such terms are defined by the federal government and whose status can be verified via the “VetBiz.Gov database” or by submission of a DD214 form.

□ Yes - Provide Letter of Verification, DD214 form or Certification Number

NOTE: If providing a Letter of Verification and/or Key Qualifier’s DD214, please label as attachment to question 1-C.

PART 2 – BUSINESS DESCRIPTION

A. Specify the business form:

□S-Corporation □Partnership □Limited Partnership □LLC

□C-Corporation □Trust □Sole Proprietorship □Other (describe):

B. Is the vendor and/or its parent company a publicly traded corporation within the United States?

□Yes □No

If you checked yes, indicate on what exchange the stock is traded symbol

C. Is the vendor and/or its parent company a publicly traded corporation outside the United States?

If you checked yes, please list the country:

D. If the vendor is not an individual, provide as an attachment labeled attachment to question 2-D the incorporation documents or registration with its corporate officers and identity of shareholders (Note: If a registration statement or pending registration statement is on file with the Securities and Exchange Commission, only the names of those persons or entities holding interest of 5% or more need be provided.)

□Not Applicable

E. Provide as an attachment labeled as attachment to question 2-E, a copy of the Business Registration Certificate or other proof of valid business registration in Massachusetts.

F. Name(s) of the vendor and the time period they were used.

List all other names under which the vendor has done business and give approximate time periods during which such names were being used:

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 7

NAME

TIME PERIOD

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-F.

G. List all addresses which the vendor held or from which it was conducting business during the last 10-year period, and give the approximate time periods during which such addresses were held:

NUMBER AND STREET

CITY

STATE

ZIP CODE

DATE

FROM: TO:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-G.

H. Identify in the table below all known and anticipated subcontractors that you will be contracting with to provide goods and/or services necessary to fulfill your contract with the

NAME OF SUBCONTRACTOR

ADDRESS

TYPES OF GOODS AND

SERVICES

CONTRACT

AMOUNT

SUBCONTRACTOR CONTRACT

PERSON IN REFERENCE TO

THIS INFORMATION

TELEPHONE

NUMBER

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-H.

I. Describe the business presently conducted and the business intended to be conducted; and the general development of the business during the past 5-years. The description should include the following:

1. Products produced and services rendered by the business and its parent, intermediary and subsidiary companies, the principal markets for said products or services and the methods of distribution;

2. A detailed account of the goods and services being provided to the gaming industry;

3. If your business is conducting or intends to conduct both gaming-related and non-gaming-related business, differentiate between the two.

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-I.

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 8

J. Stock Description (Corporation)

Describe the nature, type, terms, conditions, rights and privileges of all classes of voting, non-voting and other stock issued, or to be issued, by the corporation, including the number of shares of each class of stock authorized or to be authorized and the number of shares of each class of stock outstanding (i.e. not held by or on behalf of the issuer), as of this date.

If the right of holders of any class of stock may be modified other than by a vote of a majority or more of the outstanding shares so affected, voting as a class, so state and explain briefly:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-J.

K. Indicate in the table below all persons or entities in your business that correspond to the sub items listed below:

1. Each officer, director or trustee;

2. Each partner whether general, limited or otherwise;

3. The sole proprietor;

4. Each natural person or entity that directly or indirectly holds any beneficial or ownership interest of 5% or more of the business completing the form;

5. Each sales representative or other person who will regularly solicit or conduct business with the Commission;

6. Any other person who has signed or will sign any agreement with the Commission.

HOME ADDRESS

DATE OF

BIRTH

CURRENT TITLE

OR POSITION

OF SHARES

CLASS

OF STOCK

% OF

OWNERSHIP

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-K.

L. Other than the contract with the Commission for which the company is submitting this form, does the company have any financial or ownership interest, or other relationship with a:

Gaming Licensee or Applicant

Gaming Vendor Licensee or Applicant

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 9

If you checked "YES" to question L, explain the nature of the interest or relationship.

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-L.

M. Insurance Documents

Attach and label as attachment to question 2-M the Certificate of Insurance for the vendor demonstrating insurance and limits for liability and causality.

N. Insider Transactions (Corporation)

Furnish the information called for by the table below of each change within the last 5 years in the beneficial ownership of the equity securities of the corporation on the part of any person who is indirectly or directly a beneficial owner of more than 5% of any class of equity security of the corporation or who is or was within that period a director or officer of the corporation. (Include changes resulting from (a) gift; (b) purchase; (c) sale; (d) exercise of an option to purchase; (e) exercise of an option to sell; (f) grant or receipt of a put; or (g) grant or receipt of a call.)

TRANSACTION

NATURE OF TRANSACTION

PARTIES TO TRANSACTION

(INCLUDE POSITIONS)

# OF SECURITIES

INVOLVED

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-N.

O. Securities

Has the vendor had any securities or debt offerings suspended from trading or had any action taken against it by any financial regulatory agency?

If you checked yes, please explain:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-O.

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 10

P. Security Options1 (Business Entity)

Describe in detail any options existing or to be created with respect to securities issued by the business which description shall include, but not be limited to, the title and amount of securities subject to option, the year or years during which the options were or will be granted, the conditions under which the options were or will be granted, the consideration for granting the option and the year or years during, and the terms under which optionee becomes or will become entitled to exercise the options and when such options expire.

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-P.

Q. Identify all persons holding the options described above and include the market value of the option at the time of issuance:

NAME OF PERSON(S) HOLDING OPTIONS

MARKET VALUE OF OPTION AT TIME OF ISSUANCE

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 2-Q.

PART 3 – OWNERSHIP

A. ORGANIZATIONAL CHART

Provide as an attachment labeled attachment question 3-A an organizational chart of the business identifying its business structure and all members of the board. Include position descriptions and the names of persons holding such positions.

B. COMPENSATION OF OFFICERS AND DIRECTORS OR PARTNERS

List the total annual compensation received during the last calendar year and the amount to be received during the subsequent calendar year by each director, trustee, officer and/or partner of the business, whether such compensation is in the form of salary, wages, commissions, fees, stock options, bonuses or otherwise:

POSITIONS HELD WITH VENDOR

AMOUNT OF COMPENSATION

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 3-B.

1For the purpose of this form, option shall mean right, warrant or option to subscribe to or purchase any securities issued by the corporation.

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 11

C. COMPENSATION OVER $300,000

Furnish the information called for below as to each person, other than those listed in 3 B, who currently receives or who reasonably can be expected to receive, from the business, compensation exceeding $300,000 per annum.

BIRTH

HOME ADDRESS

POSITION AND LENGTH OF TIME

EMPLOYED WITH VENDOR

AMOUNT OF

COMPENSATION

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 3-C.

D. Does the vendor have any direct, indirect or attributed legal or beneficial interest in any business entity outside of the United States?

If you checked yes, attach a detailed statement describing the entity, its location, your affiliation, and/or interest with the foreign entity and label it attachment to question 3-D, E. INTEREST OF PARTNERS (PARTNERSHIP)

Describe the interest held by each partner, whether general or limited, in the partnership.

1. Amount of initial investment, whether in the form of cash, negotiable instruments, property or otherwise:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 3-E1

2. Amount of any additional contributions made to partnership:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 3-E2.

3. Amount and nature of any anticipated future investments:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 3-E3.

Initials/Date

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 12

4. Degree of control of each partner over the activities of the partnership:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 3-E4.

5. Percentage of ownership of each partner:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 3-E5.

6. Method of distributing profits to each partner:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 3-E6.

PART 4 – CRIMINAL HISTORY

A. The following question relates to any alleged criminal offense, arrest, misdemeanor or felony charges or conviction involving the business or agents named on its behalf. Prior to answering this question, carefully review the definitions and instructions which follow.

DEFINITIONS: For purposes of this question:

1. Arrest means being taken into custody by any police or other law enforcement authority.

2. Charge includes any indictment, complaint, information or other notice of the alleged commission of any

“offense”.

3. Conviction includes the finding of guilty of any “offense” upon a trial or a plea of guilty. An adjudication of delinquency shall not be considered a conviction. Such a finding may, however, be considered for purposes of determining the suitability of an applicant.

4. Crime or Offense includes all felonies and misdemeanors.

5. Disposition the way the case was resolved: guilty, not guilty, continued without a finding, dismissed, pending, etc.

INSTRUCTIONS: Please note, this is not an application for employment. Accordingly, you must answer all questions completely and may not omit information. Answer "Yes" and provide all information to the best of your ability, EVEN IF:

1. the business did not commit the offense charged;

2. the charges were dismissed or subsequently downgraded to a lesser charge;

3. the business completed a diversionary program or equivalent thereof;

4. the business was not convicted;

5. the charges or offenses happened a long time ago.

Has the "Entity" or any of its subsidiaries ever been charged with or convicted of a criminal offense or been a party to or named as an unindicted co-conspirator in any criminal proceeding in Massachusetts or any other jurisdiction?

Yes □ No □

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 13

If you checked YES, complete the chart below:

NATURE OF CHARGE OR

OFFENSE

DATE OF CHARGE

OR COMPLAINT

NAME AND ADDRESS OF LAW

ENFORCEMENT OR COURT INVOLVED

DISPOSITION

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 4.

PART 5 – LITIGATION AND MISCELLANEOUS VIOLATIONS

A. Existing Litigation

Describe all existing civil litigation at equity and law to which the business, or any subsidiary, is presently a part, whether in the Commonwealth of Massachusetts or in another jurisdiction.

Is the company currently a party to any civil lawsuits?

Has the company or any of its officers, executives, or managers been a party to any other litigation?

1. In the previous 10-years.

2. In which an ultimate decision could have a current or future effect on the company.

3. In which an ultimate decision could reasonably be expected to reflect upon the current or future financial responsibility or ability of the company.

4. In which an ultimate decision could reasonably be expected to reflect upon the character, reputation, or integrity, of the company or any of its officers, executives or managers.

□Yes □No

If you checked YES to any of the above questions, submit the following and labeled it as attachment to question 5-A4.

Official title or caption of the case

Docket or case number

Name and location of the court before which the case is pending

Identity of all parties to the litigation

General nature of all claims being made

B. Insolvency Proceedings & Appointed Receiver, Agent or Trustee

1. Has the company, its parent or any intermediary company, had any petition under any provision of the Federal Bankruptcy Act or under any state insolvency law filed by or against it in the last 15-year period?

2. Has the company, its parent or any intermediary company sought relief under any provision of the Federal Bank Act or under any state insolvency law in the last 15-year period?

□Yes □No Initials/Date____________________

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 14

3. Has any receiver, fiscal agent, trustee, reorganization trustee, or similar officer, been appointed, in the last 15-year period, by a court for the business or property of the business or its parent, holding, intermediary or subsidiary companies?

If you checked YES to any of the above, provide the following information on the chart below:

NAME OF PERSON APPOINTED

APPOINTED

COURT

REASON

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 5-B3.

A. Antitrust, Trade Regulation and Securities Agreements, Statutory and Regulatory Violations

1. Has the company ever had a judgment, order, consent decree, consent order pertaining to a violation, alleged violation of the federal antitrust trade regulation or securities laws, or similar laws of any state, province or country entered against the applicant?

2. In the past 10-years, has the company had a judgment, order, consent decree, consent order pertaining to a violation, alleged violation of any state or federal statute, regulation, or code that resulted in a penalty or fine of $50,000 or more entered against it?

If you checked YES, provide the following information for each judgment, order, consent decree, or consent order:

OFFENSE

NATURE OF OFFENSE

TITLE OF CASE

AND DOCKET

NAME AND ADDRESS

OF COURT OR

AGENCY

NATURE OF

JUDGMENT, DECREE

OR ORDER

ENTERED

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 5-C2.

PART 6 – REGULATION AND LICENSURE

A. Is the company subject to licensure by any governmental agency in Massachusetts or any other jurisdiction?

If you checked “YES”, provide the following information on the chart below:

NAME AND LOCATION OF PUBLIC AGENCY

TYPE OF REGULATION

LICENSE NUMBER OR

IDENTIFYING NUMBER

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 6-A.

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 15

B. Has the company ever applied, in Massachusetts or any other jurisdiction, for a license, permit or other authorization, to participate in lawful gambling operations (including casino gaming, non-profit, horse racing, dog racing, pari-mutuel operation, lottery, sport betting, etc.)?

If you checked "YES" to any of the above, provide the following information on the chart below:

NAME AND ADDRESS OF

LICENSING AGENCY

APPLICATION

DISPOSITION

TYPE OF

GAMBLING

IF ISSUED, GIVE

APPROPRIATE NUMBER

AND EXPIRATION DATE

Granted

Denied

Pending

Expired

Suspended

Conditioned

Withdrawn

Revoked

Granted

Denied

Pending

Expired

Suspended

Conditioned

Pending

Expired

Suspended

Conditioned

Pending

Expired

Suspended

Conditioned

Pending

Expired

Suspended

Conditioned

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 6-B.

C. Has the company ever had a complaint or other notice of pending disciplinary action from any jurisdiction?

During the last 10-year period has the company had any license or certificate issued by any jurisdiction denied, restricted, suspended, revoked, or not renewed?

Has the company ever withdrawn its application, license, or certificate in any jurisdiction?

Has the company ever appeared on the exclusion list in any jurisdiction?

If you checked YES to any of the above questions, submit a statement describing the facts or circumstances labeled attachment to question 6-C. If gaming-related, provide the information requested on the following chart in Section B.

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 16

PART 7 – FINANCIAL BACKGROUND

ITEM A.

List the identity of every person having a direct or indirect interest in the company and the nature of such interest.

1. If the business is a trust, list all the beneficiaries:

NAME OF BENEFICIARY

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 7-A1.

2. If the business is a partnership, list all partners, general and limited:

NAME OF PARTNER

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 7-A2.

3. If the business is a limited liability company, list all members:

NAME OF MEMBER

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 7-A3.

ITEM B.

Financial Institutions

1. Furnish the information called for in the table below with respect to each bank, savings and loan association or other financial institution, whether domestic or foreign, in which the company has or has had an account over the last 10 year period, regardless of whether such account was held in the name of the business, a nominee of the business or was otherwise under the direct or indirect control of the company.

TYPE OF ACCOUNT

ACCOUNT NUMBER(S)

FROM: TO:

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 7-B1.

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ITEM C. Financial Statements

1. Provide as an attachment labeled attachment to question 7-C1 copies of all audited or unaudited financial statements, an audited financial statement which shall include but not be limited to, an income statement, balance sheet, statement of sources, and application of funds, and all notes to such statements and related financial schedules, for the last 5 years with respect to the company and any exceptions taken to such statements by any management response.

2. If the company does not normally have its financial statement audited, attach to this form as an attachment labeled attachment to question 7-C2, all unaudited financial statements prepared in the last 5-years with respect to the company. (If the company has neither audited not unaudited financial statements prepared, please note same.)

ITEM D. Annual Reports

1. Provide as an attachment labeled attachment to question 7-D1 a copy of all annual reports of the company that were submitted to shareholders, partners, or other persons during the last 5-years.

2. A corporation that is a registrant under the Security Act of 1933, or the Securities Exchange Act of 1934, shall submit a copy of all annual reports prepared on form 10K and filed within the last 5-years. Attach to this form as an attachment labeled attachment to question 7-D2.

ITEM E. Interim Reports

Provide as an attachment labeled attachment to question 7-E a copy of all reports prepared due to the occurrence of any of the following events: change in control of the business, acquisition or disposition of assets, bankruptcy or receivership proceedings, changes in the business’s certifying accountant, or other material events. If a corporation is a registrant with the SEC, it may submit a copy of the most recent form 8K filed with the SEC in response to this item.

ITEM F. Proxy and Information Statement (Corporation)

Provide as an attachment labeled attachment to question 7-F a copy of the last definitive Proxy or Information Statement filed pursuant to Section 14 of the Securities Exchange Act of 1934.

ITEM G. Registration Statement (Corporation)

Provide as an attachment labeled attachment to question 7-G a copy of all Registration Statements filed, in the last 5-years, pursuant to the Securities Act of 1933.

ITEM H. Tax Returns

Provide as an attachment labeled attachment to question 7-H, a copy of all 1120 Forms (U.S. Corporate Income Tax Returns), or all 1065 Forms (U.S. Partnership Return), or 1040 Forms (personal tax returns) for the last 5-years. Be sure to include all schedules and attachments for these returns.

ITEM I. Description of outstanding debt

Describe the nature, type, terms, covenants and priorities of all outstanding debt of the business.

Note: Should you require additional space, attach a separate sheet of paper in the same format and label it attachment to question 7-I.

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STATEMENT OF TRUTH

I, _____________________________________________, hereby state under the pains and penalties of perjury that:

(Print Name)

1. The information contained herein and which accompanies this form is true and accurate to the best of my knowledge and understanding.

2. I personally supplied and/or reviewed the information contained in this form.

3. I understand and read the English language or I have had an interpreter read, explain and record the answer to each and every question on this form.

4. Any document accompanying this form that is not an original document is a true copy of the original document.

(Signature)

(Type, Stamp or Print Name)

(Date)

IEB Form: DISCLOSURE FOR MGC VENDOR Ver 2.0 Rev2.25.15 Page 19

RELEASE AUTHORIZATION FOR VENDOR

To: Law Enforcement Agencies, Courts, Probation Departments, Military Organizations, Selective Service Boards, Employers, Educational Institutions, Banks, Financial and Other Such Institutions, All Gaming Regulatory Agencies, and All Governmental Agencies – federal, state and local, without exception, both foreign and domestic (the “issuing entity”).

On behalf of , (Name of Vendor)

I, authorize the Massachusetts Gaming Commission (Name of President, Officer, Partner, or Sole Proprietor)

(Commission) and the Investigations and Enforcement Bureau (Bureau) to conduct a full investigation into the background and activities of said business entity.

I acknowledge that the Commission and/or Bureau may contract or may have contracted with third parties for the purpose of conducting due diligence investigations on behalf of the Commission and/or the Bureau in connection with this background check.

I authorize the release of any and all information pertaining to said entity, documentary or otherwise, as requested by any employee or agent of the Commission or the Bureau, provided that he or she certifies to you that said entity has is being evaluated as a vendor to the Commission.

I release any issuing entity, the Commission, the Bureau and their agents, representatives and employees, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result because of compliance with this authorization for release of information.

I acknowledge that this authorization shall supersede and replace any prior release authorization executed by me on behalf of said entity for the Commission and/or Bureau.

This release shall be valid from the date of signature and, once issued, for a 3 year duration.

A photocopy of this authorization will be considered as effective and valid as the original.

(Signature)

(Type, Stamp or Print Name)

(Date)

On this day of 20 , before me, the undersigned notary public, personally appeared (name of document signer), proved to me through satisfactory evidence of identification, which was , to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose.

(Signature of Notary) (Notary Stamp)