Request For W2g Or Win/loss Statement (Page 2 of 2) in pdf

Request For W2g Or Win/loss Statement Page 2

Request for W2G or Win/Loss Statement

FORM REQUESTED:

W2G (

) ______ WIN/LOSS

) ______

Jackpot(s) Won

Coin In/Coin Out

(

(Bets wagered during the year, not dollar amount)

IF OTHER THAN CURRENT TAX YEAR, SPECIFY YEAR(S): _________________________________

Name: __________________________________________________________________

Lucky 7 Club Account #:____________________________________________________

Phone #:_____________________________Date of Birth: ________________________

Current Address: _________________________________________________________

City, State, Zip: ___________________________________________________________

State Issued ID#:__________________________________State:___________________

SSN #:___________________________________________________________________

Please read this important disclaimer:

The information provided in these reports is an estimate only, and should not

be relied upon for tax purposes. Estimates of slot machine activity is based

upon electronically recorded data, which may not be reliable due to various

factors, including the fact that we cannot verify either that a player uses his

or her player’s card at all times or that the recorded activity only represents

activity of the registered cardholder. We wish to emphasize that it is the

responsibility of each player to maintain accurate records of his or her own

play. However, we are pleased to provide this information to you, our valued

customer, with the hope that it will assist you in corroborating your own

record of play.

________________________________________

_________________

Signature

(When Requesting Info)

Date

***PATRON MUST SHOW VALID PHOTO ID TO RECEIVE FORM(S) ***

_______________________________________

_________________

Signature (Sign Here When Received)

Date

FOR OFFICE USE ONLY: Player’s State Issued ID#: __________________________________ State _____

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Request For W2g Or Win/loss Statement Page 2