HIGH WINDS CASINO STATEMENT REQUEST

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Use for requesting your Win/Loss Statements, 1099 and W2G Forms

What are you wanting to request? *

Win/Loss Statement

1099

W2G

Required

Name *

First, middle, and last name

Player's Card Number *

Any aliases or previous last names?

Street Address *

City *

State *

Zip Code *

Phone number *

Date of Birth *

YYYY

Year(s) Requesting *

Social Security Number - Must be provided for these requests. *

How would you like to receive your statements? *

Email Address

Do you agree? *

This document is not verifiable as a win/loss statement reflecting actual wagering activity and cannot be used for tax purposes. I hereby authorize High Winds Casino to release its officers, directors, employees, and agents from and against any loss, cost, expense (including attorney's fees and cost), damages, liability or claims or any kind. I agree to indemnify High Winds Casino from and against any and all suits, causes of action, liabilities, costs, losses, damages, and attorney's fees and costs which I or my spouse, administrators, executors, agents, assignee's or any third party may have arising out of or relating to this request.

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