Get Horseshu W-2G

W-2G / WIN-LOSS REQUEST FORM Please print clearly. FIRST NAME MIDDLE STREET ADDRESS CITY SOCIAL SECURITY NUMBER required for W-2G PHONE NUMBER STAR AWARDS NUMBER E-MAIL ADDRESS LAST STATE ZIP CODE DATE OF BIRTH mm/dd/yyyy TAX YEAR REQUESTED PLEASE CHECK ONE OR BOTH OF THE FOLLOWING Win-Loss Statement A single page letter showing estimated play activity wins or losses based upon observable and/or carded gaming activity. W-2G Data If you have won one or more jackpots exceeding 1 200 a report summarizing these winnings is available. Request Agreement I certify that the statements contained herein are true and correct and I hereby request that the Ameristar property indicated below provide me with the information requested above. W-2G / WIN-LOSS REQUEST FORM Please print clearly. FIRST NAME MIDDLE STREET ADDRESS CITY SOCIAL SECURITY NUMBER required for W-2G PHONE NUMBER STAR AWARDS NUMBER E-MAIL ADDRESS LAST STATE ZIP CODE DATE OF BIRTH mm/dd/yyyy TAX YEAR REQUESTED PLEASE CHECK ONE OR BOTH OF THE FOLLOWING Win-Loss Statement A single page letter showing estimated play activity wins or losses based upon observable and/or carded gaming activity. W-2G Data If you have won one or more jackpots exceeding 1 200 a report summarizing these winnings is available. Request Agreement I certify that the statements contained herein are true and correct and I hereby request that the Ameristar property indicated below provide me with the information requested above. I understand that it is my own responsibility to maintain accurate records of play and that the information I am requesting consists of estimates only and may not be appropriate for income tax reporting. In consideration of my receipt of this information I agree to indemnify and hold harmless Ameristar Casinos Inc* its subsidiaries and affiliates including the Ameristar property indicated below and their respective officers directors employees and agents from any and all claims suits causes of action liabilities costs losses damages and expenses including attorney s fees and costs which I or my administrators executors agents successors heirs or assigns or any third party might have or incur as a result of or in any way relating to my receipt and/or use of the information* SIGNATURE REQUIRED TODAY S DATE If the Account Holder does not present this request in person the Account Holder s signature must be notarized* SUBSCRIBED AND SWORN TO before me the day of 20. NOTARY PUBLIC Please completely fill out the request form and return it to For Internal Use Only Cactus Petes / Horseshu Rec d / Comp By Attn Finance Department-Win/Loss Request F M P PO Box 508 Jackpot NV 89825 Fax to 775. 755. 2796 / For additional information call 800. 821. 1103 ext. 6709 CACTUS PETES / HORSESHU CONFIDENTIAL. W-2G / WIN-LOSS REQUEST FORM Please print clearly. FIRST NAME MIDDLE STREET ADDRESS CITY SOCIAL SECURITY NUMBER required for W-2G PHONE NUMBER STAR AWARDS NUMBER E-MAIL ADDRESS LAST STATE ZIP CODE DATE OF BIRTH mm/dd/yyyy TAX YEAR REQUESTED PLEASE CHECK ONE OR BOTH OF THE FOLLOWING Win-Loss Statement A single page letter showing estimated play activity wins or losses based upon observable and/or carded gaming activity. W-2G Data If you have won one or more jackpots exceeding 1 200 a report summarizing these winnings is available. .