Gaming Activity Report Request Form

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GAMING ACTIVITY REPORT & W2-G REQUEST FORM
Please print all information clearly.
____________________________________________________________________________
First Name
Middle
Last Name
____________________________________________________________________________
Street Address
City
State
Zip Code
____________________________________________________________________________
Last 4 Digits of SSN
mychoice Account Number
Date of Birth (mm/dd/yyyy)
_________________________________________________________________________
Phone Number
Tax Year(s) Requested
Do you request a gaming activity report?
Yes___ No___ Year(s) _____________
Do you request a copy of your W2-G(s)?
Yes___ No___ Year(s) _____________
______________________________________________________________________
Acknowledgment
I certify that the statements contained herein are true and correct, and hereby request that L’Auberge Baton Rouge provide me
with the information requested above. I understand that it is my own responsibility to maintain accurate records of play that, the
Gaming Activity Report is not an accounting record and is not appropriate for income tax reporting.
______________________________________________________________________
____________________________________________________________________________
Signature (Required)
Date
*Notary   n ot   r equired   i f   f orm   i s   r equested   o r   p resented   i n   p erson.
State of: _____________________)
Acknowledged before me on this the _____
) ss
day of _____________________, _______
County of: ____________________)
___________________________________
Notary
(Seal)
Please complete the request form and return it to:
Preferred Delivery Method
L’Auberge Casino Hotel Baton Rouge
Attn: Gaming Activity Report
Fax ____________________
777 L’Auberge Avenue
Baton Rouge, LA 70820
Mail ____________________
Phone Number: (225) 215-7777
Toll Free: (866) 261-7777
Please Allow 1-3 Weeks for Processing Your Request.

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