FINAL FANTASY XI NOTARIZED ACCOUNT VERIFICATION DECLARATION

I, _____________________________ (name of customer) do hereby declare, under penalty of

perjury under the laws of the United States and the State of ___________________ (State of
customer’s current location), that the following statements are true and correct.

1. My name is __________________________ (name).

2. I am the original registrant or user of the PlayOnline account _____________ (POLID).
3. My address at the time of initial registration was ______________________ (street),
_____________________ (city) _____________ (state) ____________ (zip code).
4. My current address is______________________ (street), ________________ (city)
_____________ (state) ____________ (zip code) _____________________ (email).
5. My account was compromised by an unknown third party around ______________ (date).
6. I have never sold, lent, or transferred this PlayOnline account or my password to another
person or entity.
7. I understand that I have no legal right to the return of my compromised PlayOnline account,
and that the submission of this signed and notarized form to Square Enix, Inc. is no
guarantee that I will obtain a return of this account.

Signed on ________________ (today’s date) at ______________________ (street),

__________ (city) _____________ (state) ____________ (zip code), in the presence of a
notary public.

Name:_____________________________ (signature)

State of ___________________
County of __________________

Subscribed and sworn to (or affirmed) before me on this _____________ (date of notarization)
by ______________________ (Name of Signer), personally known to me or proved to me on
the basis of satisfactory evidence to be the person who appeared before me.

____________________________ (Place notary seal here -->)

Signature of Notary

Mail the ORIGINAL full-executed and completed form to:

Square Enix, Inc., attn: PlayOnline, 999 N. Sepulveda Blvd., 3rd Floor, El Segundo, CA 90245.