Transfer of an Interest Or a Notional Interest in A

ABN 19 040 349 865

SECTION 71EI RETURN

TRANSFER OF AN INTEREST OR A NOTIONAL INTEREST IN A

GAMING MACHINE BUSINESS

(Section 71EI Stamp Duties Act, 1923)

(This form is to be lodged together with a completed Application for Opinion form and with the

instrument described in Part 1 of this Return)

1.PARTY DETAILS

Name/s of transferor/s

*

NAME /

ADDRESS

Pursuant to an instrument(s) dated theday of 200 , the above transferor/s will convey an interest or a notional interest in a Gaming Machine Business known as……………….…………………………

at (address)………………………………………………………………………………………………….

to: (names of transferee/s)

*

NAME /

ADDRESS

2.TRANSACTION DETAILS

Is the whole of the interest in the Gaming Machine Business being transferred by this transaction? If Yes – tick Box, and go to Part 3.

If less than the whole of the interest in the Gaming Machine Business is being transferred, complete the following details:

(a) Value of Gaming Machine Business

The value of the Gaming Machine Business described above as at the date of the instrument is $…………………………..

• If insufficient space is available attach a schedule listing all the names and addresses of the parties.

(b) Indirect/Notional Interest Transaction

Provide details and evidence of the ownership structure of the related entities (both beneficial and legal) to enable the calculation of the notional interests of the parties.

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

(If space is insufficient, please use an attachment setting out the details.)

(c)What was the total percentage of the interest/notional interest the transferor(s) held in the Gaming Machine Business immediately prior to the date of the instrument?

*

NAME / PERCENTAGE HELD %

(d) What is the total percentage of the interest/notional interest held by the transferor(s) in the Gaming Machine Business immediately after the date of the transaction?

*

NAME / PERCENTAGE NOW HELD %

(e) Express the difference between (c) and (d) as a percentage and as a fractional value of the value of the Gaming Machine Business.

*

NAME /

PERCENTAGE DIFFERENCE %

/

$ FRACTIONAL VALUE

3.NET GAMBLING REVENUE

List the Net Gambling Revenue (NGR) received by the Gaming Machine Business for each of the 12 complete calendar months prior to the date of the instrument, or all complete calendar months that the Gaming Machine Business was carried on, if operational for less than 12 calendar months prior to the date of the instrument.

Note:

• Net Gambling Revenue is defined at Section 72 of the Gaming Machine Act 1992.
• If insufficient space is available attach a schedule listing all the names and addresses of the parties.

CALENDAR MONTH

/

NGR

$

January
February
March
April
May
June
July
August
September
October
November
December

TOTAL NGR $

4.I/We the transferor/s (or agent) make the statements in this Return believing that all the information provided in connection with the above transaction(s) is true and correct and there are no material omissions.

N.B.

If a statement relating to a transaction to which this Division applies is not lodged within 2 months of the date of the transaction and the relevant surcharge paid, a penalty up to $10,000 may apply pursuant to Section 71EI of the Stamp Duties Act 1923.

This Return must be executed by the transferor/s (or their agent) and transferee/s (or their agent) to the instrument described in Part 1. If insufficient space is available on this page, copy this page for execution by the remaining parties and attach to this Return.

Executed by the transferor/s/agent:

Signature:...... Signature:......

Name:...... Name:

Signature ofSignature of

Witness:...... Witness:......

Name ofName of

Witness:...... Witness:......

Address ofAddress of

Witness:...... Witness:......

......

......

Date: / / Date: / /

The Common Seal of

Was hereunto affixed in the presence of

…………………………………………..

Director

………………………………………….

Secretary

Date: / /

The Common Seal of

Was hereunto affixed in the presence of

…………………………………………..

Director

………………………………………….

Secretary

Date: / /

Executed by the transferee/s/agent:

Signature:...... Signature:......

Name:...... Name:

Signature ofSignature of

Witness:...... Witness:......

Name ofName of

Witness:...... Witness:......

Address ofAddress of

Witness:...... Witness:......

......

......

Date: / / Date: / /

The Common Seal of

Was hereunto affixed in the presence of

…………………………………………..

Director

………………………………………….

Secretary

Date: / /

The Common Seal of

Was hereunto affixed in the presence of

…………………………………………..

Director

………………………………………….

Secretary

Date: / /