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Get MO River City Casino W-2G/Win-Loss Request Form

In consideration of my receipt of this information I agree to indemnify and hold harmless River City its subsidiaries and affiliates 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 incure as a result of or in any way relating to my receipt and/or use of the information. Signature Required Date Please complete the request form and return it to River City Casino Attn Win-Loss Requests 777 River City Casino Blvd. W-2G/WIN-LOSS REQUEST FORM Please print all information clearly. First Name Middle City Street Address Social Security Number required for W2-G Phone Number Last Name State Club Account Number Email Address Zip Code Date of Birth mm/dd/yyyy Tax Year Requested Please Check one or both of the Following - Win-Loss Statement Document indicates estimated play activity wins or losses based upon observable and/or carded gaming activity. - W-2G IRS form summarizing jackpots won that exceed 1 200. Request Agreement I certify that the statements contained herein are true and correct and hereby request that River City 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. W-2G/WIN-LOSS REQUEST FORM Please print all information clearly. First Name Middle City Street Address Social Security Number required for W2-G Phone Number Last Name State Club Account Number Email Address Zip Code Date of Birth mm/dd/yyyy Tax Year Requested Please Check one or both of the Following - Win-Loss Statement Document indicates estimated play activity wins or losses based upon observable and/or carded gaming activity. - W-2G IRS form summarizing jackpots won that exceed 1 200. Request Agreement I certify that the statements contained herein are true and correct and hereby request that River City provide me with the information requested above. - W-2G IRS form summarizing jackpots won that exceed 1 200. Request Agreement I certify that the statements contained herein are true and correct and hereby request that River City 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. W-2G/WIN-LOSS REQUEST FORM Please print all information clearly. First Name Middle City Street Address Social Security Number required for W2-G Phone Number Last Name State Club Account Number Email Address Zip Code Date of Birth mm/dd/yyyy Tax Year Requested Please Check one or both of the Following - Win-Loss Statement Document indicates estimated play activity wins or losses based upon observable and/or carded gaming activity. - W-2G IRS form summarizing jackpots won that exceed 1 200. Request Agreement I certify that the statements contained herein are true and correct and hereby request that River City 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. .

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