SCHEDULE 6(Section 71, subsection 131(3) and section 152)Report with Respect to Casino Disbursements
PART A
Information with Respect to Reporting Person or Entity and Place of Business Where Disbursement Is Made
1*
Person’s or entity’s name
2*
Identification number assigned to person or entity by Centre
3*
Number that identifies place of business
4*
Address of place of business
5*
Contact person’s name
6
Contact person’s e-mail address
7*
Contact person’s telephone number
PART B
Information with Respect to Disbursement
1*
Date of disbursement
2*
Time of disbursement
3*
Type and amount of disbursement
4*
If disbursement is in funds, type and amount of each type of funds involved
5*
If disbursement is not in funds, type of disbursement and its value
6*
Method by which disbursement is made
7*
Name of every person or entity involved in disbursement and their account number or policy number or, if no account number or policy number, identifying number
8*
Type of transaction in which disbursement occurs
9*
Purpose of disbursement
PART C
Account and Reference Number Information
1*
Every account number and other equivalent reference number connected to transaction in which disbursement occurs
2*
Type of account
3*
Branch number, institution number and similar numbers connected to account or reference number
4*
If account is casino account, address of casino where account is located
5*
Name of each account holder
6*
Type of fiat currency of account
7
Date account opened
PART D
Information with Respect to Person Who Requests Disbursement
1*
Person’s name
2
Person’s alias
3*
Person’s date of birth
4*
Person’s address
5
Person’s country of residence
6
Person’s email address
7
Person’s telephone number
8*
Nature of person’s principal business or their occupation
9
Identification number assigned to person by casino
10*
Type of document or other information used to identify person, or to verify their identity, and number of document or number associated with information
11*
Jurisdiction and country of issue of document or other information
12
Name of person’s employer
13
Type of device used by person who requests disbursement online
14
Number that identifies device
15
Internet Protocol address used by device
16
Person’s user name
17
Date and time of person’s online session in which disbursement is requested
PART E
Information with Respect to Entity That Requests Disbursement
1*
Entity’s name
2*
Entity’s address
3
Entity’s telephone number
4*
Nature of entity’s principal business
5
Identification number assigned to entity by casino
6*
Name of each person — up to three — who is authorized to bind entity or to act with respect to account
7*
Type of document or other information used to identify entity, or to verify its identity, and number of document or number associated with information
8*
Jurisdiction and country of issue of document or other information
9
Type of device used by entity that makes request online
10
Number that identifies device
11
Internet Protocol address used by device
12
Entity’s user name
13
Date and time of entity’s online session in which disbursement is requested
PART F
Information with Respect to Person or Entity on Whose Behalf Disbursement Is Requested
1*
Person’s or entity’s name
2*
Person’s or entity’s address
3
Person’s or entity’s email address
4
Person’s or entity’s telephone number
5*
Nature of person’s or entity’s principal business or their occupation
6
Identification number assigned to person or entity by casino
7
Type of document or other information used to identify person or entity, or to verify their identity, and number of document or number associated with information
8
Jurisdiction and country of issue of document or other information
9*
Relationship of person or entity to person or entity that requests disbursement
10
In the case of a person,
(a)
their alias
(b)
their date of birth
(c)
their country of residence
(d)
their employer’s name
11
In the case of an entity,
(a)
name of each person — up to three — who is authorized to bind entity or to act with respect to account
(b*)
its registration or incorporation number and jurisdiction and country of issue of that number
PART G
Information with Respect to Person or Entity That Receives Disbursement (if Different from Person or Entity in Part D, E or F)
1*
Person’s or entity’s name
2*
Person’s or entity’s address
3
Person’s or entity’s email address
4
Person’s or entity’s telephone number
5
Nature of person’s or entity’s principal business or their occupation
6
Identification number assigned to person or entity by casino
7
Type of document or other information used to identify person or entity, or to verify their identity, and number of document or number associated with information
8
Jurisdiction and country of issue of document or other information
9*
Relationship of person or entity to person or entity that requests disbursement
10
Relationship of person or entity to person or entity on whose behalf disbursement is requested
11
User name of person or entity that receives payment online
12
In the case of a person,
(a)
their alias
(b)
their date of birth
(c)
their country of residence
(d)
their employer’s name
13
In the case of an entity,
(a)
name of each person — up to three — who is authorized to bind entity or to act with respect to account
(b)
its registration or incorporation number and jurisdiction and country of issue of that number
