SCHEDULE 8(Subsections 42(1), (3) and (4))Large Casino Disbursement Report
PART A
Information on Place of Business Where Disbursement Is Made
1*
Identification number of place of business where disbursement is made (e.g., casino’s identification number, licence number or other identifying number), if applicable
2*
Full name of reporting person or entity
3*
Full address of place of business where disbursement is made
4*
Name and telephone number of contact person
PART B
Information on Disbursement
1*
Date of disbursement
2
Time of disbursement
3*
Purpose and details of disbursement
(a)
reason for disbursement (chip redemption, gaming voucher redemption, payout or other reason), amount received, currency of amount received
(b)
type of disbursement (cash, cheque, electronic funds transfer, deposit in account at financial institution or other form of disbursement), amount disbursed and currency of amount disbursed and, if applicable, name and account number of each person involved in the disbursement, other than a person referred to in item 2 of Part A or Part D or F, and branch or transit number of each of those accounts, and name and account number of each entity involved in the disbursement, other than an entity referred to in item 2 of Part A or Part E, and branch or transit number of each of those accounts
4*
Method by which the disbursement is made (in person, by armoured car or by another method)
PART C
Casino Account Information (if applicable)
1*
Account number
2*
Casino Identifier Number, if applicable
3*
Type of account (credit, front money or other type of account)
4*
Full name of each account holder
5*
Type of currency of the account
PART D
Information on Person Requesting Disbursement
1*
Person’s full name
2
Client number provided by reporting person or entity, if applicable
3*
Person’s full address
4
Person’s personal telephone number
5
Person’s country of residence
6*
Person’s type of identifier (e.g., driver’s licence, birth certificate, provincial health insurance card — if such use of the card is not prohibited by the applicable provincial law — or passport) and identifier number
7*
Place of issue of person’s identifier (province or state, country)
8*
Person’s date of birth
9
Person’s business telephone number
10*
Person’s occupation
PART E
Information on Entity on Whose Behalf Disbursement Is Received (if applicable)
1*
Entity’s full name
2*
Entity’s incorporation number and jurisdiction of its incorporation, if applicable
3*
Entity’s type of business
4*
Entity’s full address
5
Entity’s telephone number
6
Full name of each person — up to three — who is authorized to bind the entity or act with respect to the account
PART F
Information on Person on Whose Behalf Disbursement Is Received (if applicable)
1*
Person’s full name
2*
Person’s full address
3
Person’s personal telephone number
4
Person’s business telephone number
5
Person’s type of identifier (e.g., driver’s licence, birth certificate, provincial health insurance card — if such use of the card is not prohibited by the applicable provincial law — or passport) and identifier number
6
Place of issue of person’s identifier (province or state, country)
7
Person’s date of birth
8
Person’s occupation
9
Person’s country of residence
10
Relationship of person requesting the disbursement to the person on whose behalf the disbursement is received
