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Get Choctaw Casino Win/Loss or Tax Information Request Form

Please Return form to Choctaw Casino Attention Cage Accounting 3400 Choctaw Rd Pocola Ok 74902 Phone 918-436-7761 Fax 918-436-7606 Win/Loss or Tax Information Request Form Name / Players Club Card Last Name First Name Social Security Number Date of Birth Month Mailing Address Day Year Street Address or P. O. Box Apartment Number City State Telephone Zip E-Mail if applicable Please provide me with a statement of my activity for the tax year s The following document s Please Check Win/Loss Statement W2G 1099 s can be requested after February 1st for the previous tax year. All requests must be sent to Choctaw Nation of Oklahoma Finance Department Attn Stacey Workman P. O. I hereby i.e.. Jane Doe authorize Choctaw Casinos to provide me with the above checked statement s. By signing below I agree to release Choctaw Casinos its officers directors associates and agents from any loss cost expense including attorney s fees and costs damages liability or claims of any kind. I agree to indemnify administrators executors agents assignees or any third party may have arising out of or relating to this request. O. Box Apartment Number City State Telephone Zip E-Mail if applicable Please provide me with a statement of my activity for the tax year s The following document s Please Check Win/Loss Statement W2G 1099 s can be requested after February 1st for the previous tax year. All requests must be sent to Choctaw Nation of Oklahoma Finance Department Attn Stacey Workman P. O. 1210 Durant OK 74701 I hereby certify that the information and statements contained herein are true and correct. I hereby i*e*. Jane Doe authorize Choctaw Casinos to provide me with the above checked statement s. By signing below I agree to release Choctaw Casinos its officers directors associates and agents from any loss cost expense including attorney s fees and costs damages liability or claims of any kind* I agree to indemnify administrators executors agents assignees or any third party may have arising out of or relating to this request. If this Information is not obtained then the request will not be completed Sites Check all that apply-W2G s Only Resort Pocola Too Atoka Stringtown Durant Too McAlester BRD Idabel Broken Bow Poteau Pocola Grant Wilburton Casino Guest s Authorized Signature Date Casino Associate Issuing Copies Disclaimer The information contained in this transmission is intended only for the use of the recipient s named above. It may contain proprietary confidential or privileged information of the sender. If you are not the intended recipient you are hereby notified that any disclosure dissemination distribution or copying of the information contained in this transmission is strictly prohibited* If you have received this transmission in error please notify the sender immediately by reply and delete the original message. DO NOT WRITE BELOW THIS LINE* FOR CHOCTAW CASINOS USE ONLY. Identification Type Provided W-9 Photo Identification Verifier s Signature and Date. All requests must be sent to Choctaw Nation of Oklahoma Finance Department Attn Stacey Workman P. O. 1210 Durant OK 74701 I hereby certify that the information and statements contained herein are true and correct. .

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