Tax Information Statement Request Form printable pdf download

Tax Information Statement Request Form

Please fill out this request form completely and sign. It is in the best interest to use blue or black ink and print clearly so we

can process your request. Please allow up to two (2) weeks to process this request once received. You may mail, email, or

fax your completed Tax Information Statement Request form. You may also view and/or print your tax information by

signing into your account. Please note we do require a signed form for all requests.

Mail:

M life Member Services

Fax:

email:

3549 Industrial Road

Attn. Member Services

Las Vegas, NV 89109

1-866-443-4941

For privacy purposes, the requested Tax Information Statement will be mailed to the address we have on file for your M life

account unless you specify another address below. If you select for us to email your win/loss statement, we will send it to the

email address linked to your M life number. You may verify your current mailing address by visiting any M life desk,

logging on to or by calling 866.752.7111. Your Tax Information Statement will include estimated Slot and Table

Games win/loss information from the following properties: Aria, Bellagio, MGM Grand Las Vegas, Mandalay Bay, The

Mirage, Monte Carlo, New York-New York, Luxor, Excalibur, Beau Rivage, Gold Strike Tunica and MGM Grand Detroit.

The tracking system used to arrive at the amount on your Tax Information Statement is dependent upon use of your M life

card and does not include slot tournament or giveaway party winnings, race and sports book, poker or keno activity.

Therefore, your statement will not reflect an accurate accounting record – it merely provides an estimate you can use to

compare to your own records.

Today’s Date __ __

__ __

__ __ __ __

_______________________ ________________ _______________________________

Guest Name:

First Name

Middle Initial

Last Name

Date of Birth __ __

__ __

__ __ __ __

M life Number __ __ __ __ __ __ __

Tax Identification Number or Social Security Number (last four digits only) __ __ __ __

Please note, we can only provide the past seven (7) years. You can also view your past 7 years online by logging into

. Clearly print the years in which you are requesting your tax statement.

____________ ____________ ____________ ____________ ____________ ____________ ____________

Indicate whether you would like to receive your tax information quarterly or yearly:

I would like to see this statement with a quarterly breakdown.

I would like to see this statement with a yearly breakdown.

Please send it by:

U.S. Mail

Fax (______) _____________________

Specify an Alternate Delivery Address: Business Name ____________________________________________________

Address ____________________________ City__________________________ State______ Postal Code: ____________

I do herby certify that the information contained herein is true and correct, and I hereby authorize MGM Resorts International, its Subsidiaries, Affiliates

and Agents, to provide to me a win/loss statement of my gaming activities derived from my M life account history. In consideration for this, I agree to

indemnify and hold harmless MGM Resorts International and its past and present agents, directors, employees, managers, representatives, officers,

successors, affiliated persons, organizations and companies from any and all claims, causes of action, liabilities, costs or damages arising from or relating

to the information and its release as a result of this request.

I understand that the information requested is generated from internal marketing systems and is not intended to be or take place of my own records of my

gaming activity. MGM Resorts International makes no representation or warranty, express or implied, as to the accuracy of this information or its

effectiveness as proof of losses.

Customer Signature _________________________________________________________ Date _____________________