Instructions to completing this form

Golden Casket Lottery Corporation Limited - December 2010 - Form No. 04-41-0008

A. Change of Name onWinners Circle Card

B. Add Remove or Replace a Name onWinners Circle CardPlease select:

Current Name

Current Name/s

New Name

Signature

Signature

Signature

Winners Circle Card Number:

* Please complete section C overleaf where a player is being removed from the card** Any outstanding prizes of un-presented cheques can be paid into the Deceased’s Estate or the Beneficiaries of the Will

This form is to be used if you wish to change your name that currently appears on your Winners Circle card.

Step 1: Complete the form legibly using black inkStep 2: Photocopy supporting documentation that has been certified by a JP, Commissioner for Declaration, or SolicitorStep 3: Attach copies of identification to this form and mail to:

Golden Casket Lottery Corporation LimtedLocked Bag 7Coorparoo DC, QLD 4151Or Scan and email documentation, to playersupport@goldencasket.com

Date of Birth

/ /

Date of Birth

/ /

DeathCertificate**

Driver’sLicence

Will orProbate Will**

BirthCertificatePassport 18+

cardConcessionCard (copy both sides)

MarriageCertificate

DivorcePapers

DriversLicence

DeedPoll

BirthCertificate

ID provided (refer to list below)

/ /Current Address on Winners Circle Card

Postcode

Name/s to be Added or Removed* SignatureDate of Birth

/ // /

CHANGE OFWINNERS CIRCLE CARD DETAILS

Daytime Contact No.

Date:Customer identification hasbeen sited, verified and attached?

Signature ofverifying officer:

The personal information sought in this document is sought by Golden Casket Lottery Corporation Limited. The information sought in this form is required to keep current your WinnersCircle cardholder details so we can continue to provide you with the benefits of being a cardholder and to enable Golden Casket to keep you informed of its lottery promotions andlottery products. A failure to keep current the cardholder information you provide to Golden Casket may impact adversely on Golden Casket's communications with you.

We may disclose your personal information to third parties, including your and our financial institutions, our selling agents, our contractors (such as mail suppliers, IT suppliers andmarketing services), our professional advisers and gaming regulators and legal enforcement agencies.You are entitled to have access to your personal information. Access can beobtained by contacting us on 131 868.

Unless you tell us otherwise, we will assume you consent to the above collection, uses and disclosures. For more information see our Privacy Policy at www.goldencasket.com orcontact us on 131 868. We may change this Privacy Statement from time to time. If we do, these changes will be reflected in our Privacy Policy.

As of the effective date I hereby relinquish any and all rights to :

I hereby remove my name from Winners Circle Card number:

a) Un-presented cheque number/s for :and / or

Please return this form completed to Golden Casket Lottery Corporation Limited. Locked Bag 7 Coorparoo DC., QLD. 4151.

I solemnly declare that I am

And I direct Golden Casket Lottery Corporation Limited (ABN 27 078 785 449) to make any and / or future payment of prizes associated

with Winners Circle Card number to the remaining card holders/s or as directed by the

card holders/s. I make this solemn Declaration conscientiously believing the same to be true, and by the virtue of the provisions of the

“Oaths Act of 1867".

(A Justice of the Peace / Commissioner for Declarations / Notary Public / Lawyer)

(Signature of person being removed)

(Please print name in full)

Taken and declared before me at

* Please note, any changes, alterations including whiteout to bank details must be initialled by the claimant.

Would you like the prize claim to be paid by or *CHEQUE BANK TRANSFER (complete bank details below)

Bank / Building Society or Credit Union Name

Branch Location

Branch (BSB) No.

Account Name

Account No.

Claimant’s Signature

Golden Casket Use Only

Privacy Statement

C. Relinquish OwnershipThis section is completed by the player/s being removed, so they may relinquish the rights to any current un-presentedcheques, unpaid prizes or future prize wins on the Winners Circle Card

b) Any unpaid prizes on ticket number/s for :and / or

c) Any future prizes associated with this Winners Circle card.

of(Please print residential address in full)

/ /

D. Change of Name on Unpresented ChequesThis section is completed where the player being removed, has relinquished the rights to un-presented prize cheques.The current card holder/s must complete the details below and provide proof of identify.

day of 20this

Golden Casket Lottery Corporation Limited | ABN 27 078 785 449 | call us on 131 868 |Locked Bag 7, Coorparoo DC QLD 4151 | www.goldencasket.com