W-2g, Form 1099, Or Win/loss Statement Request Form
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1W-2G, FORM 1099, OR WIN/LOSS STATEMENT
REQUEST FORM
In order for the Kiowa Casino to release any information, each guest is required to submit a signed request form for the release of
the information. Only official request forms will be accepted for processing.
This request form should only be used by guests who are Reward’s Club Members, have utilized their card for play, or have
received a W-2G or Form 1099. The Kiowa Casino does not track play that is not associated with a guest’s Reward’s Club account.
For more information regarding claiming and filing of gambling winnings guests are encouraged to contact the IRS or their tax
advisor.
Please complete all applicable blanks. Bolded sections are required:
Name: ____________________________________________________ Reward’s Club #: ________________________________
Social Security #: ___________________________________________ Date of Birth: ___________________________________
Mailing Address: ___________________________________________________________________________________________
City/State/Zip: _____________________________________________________________________________________________
Telephone #: ______________________ Fax #: _________________________ Email: ___________________________________
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Please send requested documents by:
Mail
Fax
Email
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Document(s) requested:
W-2G
Form 1099
Win/Loss Statement
Gaming activity for year(s): ____________________________________________________________________________________
By signing below, I, the guest, hereby release the Kiowa Casino, its officers, directors, team members, and agents from and against
any loss, cost, expense, including attorney’s fees and costs, damages, liability, or claims of any kind. Additionally, I, the guest,
hereby agree to indemnify the Kiowa Casino for, from, and against any loss, cost, expense, including attorney’s fees and costs,
damages, liability, or claims of any kind related to the release of this information. I, the guest, acknowledge that the information
being provided is based on player tracking information which includes only the play when my Reward’s Club card was connected
to the system and may not accurately reflect the amount of my actual play since I, the guest, can play when the card is not
connected to the system and is derived from a system that does not verify the identity of the person using the Reward’s Club card
and may include estimated amounts to correct error in inputting information.
***A copy of your driver’s license is required to be attached to this form for verification purposes.
Guest’s Signature: ____________________________________________________________ Date: _________________________
Submit to: Kiowa Casino
Any questions: Call (580) 299-3514
Attn: Compliance Department
198131 HWY 36
Devol, Oklahoma 73531-4232
Fax (580) 299-3689
Email:
P:
F:
198131 HWY 36 • Devol, Oklahoma 73531
866.370.4077
580.299.3486 |
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