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Timothy Johnson EX-1248 10614-2022

Create: Thu, 07/13/2023 - 22:14

Author: admin

Timothy

Johnson

EX-1248

10614-2022

Thu, 12/15/2022 - 19:00

Timothy_Johnson.pdf71.57 KB

PENNSYLVANIA

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

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LAST NAME:

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HOME ADDRESS:

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Address

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PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

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Complaint Number:

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ONLINE SITE USED:

Online Site Used*

DEVICE TYPE:

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USER/SCREEN NAME USED:

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Please provide a summary of the incident or dispute to the best of your knowledge. Include any statements which you made to the licensed gaming entity's personnel or any statements you made to witnesses to the incident or dispute.

Please provide a summary of the incident or dispute to the best of your knowledge. Include any statements which you made to the licensed gaming entity's personnel or any statements you made to witnesses to the incident or dispute.

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