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Get Hard Rock Hotel & Casino Win/Loss Statement Request

If this request is not presented in person request must be notarized. Please mail the original request to Hard Rock Hotel Casino Sioux City Win/Loss Statement Request 111 3rd Street Sioux City IA 51101. City State Account Holder s Signature Holder may receive or request a Win/Loss Statement. Account Holder MUST present valid government issued photo ID acceptable to SCE Partners LLC in its sole and absolute discretion. SUBSCRIBED AND SWORN TO before me the NOTARY PUBLIC COUNTY STATE DO NOT WRITE IN THIS BOX - FOR HARD ROCK HOTEL CASINO SIOUX CITY USE ONLY VALID GOVERNMENT ISSUED IDENTIFICATION TYPE INSERT VALID GOVERNMENT ISSUED Notarized Valid Photo ID Verified Verifier s Signature and Date Please present this request to the Backstage Pass Rewards Club Desk at Hard Rock Hotel Casino Sioux City. WIN/LOSS STATEMENT REQUEST Name Telephone Date of Birth Casino Email Address Account Number Mailing address City/State/Zip Is this a change of address YES NO please circle Please provide me with a statement of my gaming activity for the year Please Circle. We do not provide current year statements. I do hereby certify that the statements contained herein are true and correct and I hereby authorize SCE Partners LLC its subsidaries affiliates and agents to provide to me a win/loss statement of my gaming activity derived from the above referenced account. I agree to indemnify and hold harmless SCE Partners LLC and its respective past and present agents employees managers representatives officers directors successors and affiliated persons organizations and companies from any and all suits causes of action liabilities costs losses damages attorney s fees and expenses which I or my administrators executors agents assignees or any third party may have arising out of or relating to this request as a result of this request. ACCOUNT HOLDER S SIGNATURE IS REQUIRED BELOW In witness whereof I have executed this request at on the day of. WIN/LOSS STATEMENT REQUEST Name Telephone Date of Birth Casino Email Address Account Number Mailing address City/State/Zip Is this a change of address YES NO please circle Please provide me with a statement of my gaming activity for the year Please Circle. We do not provide current year statements. I do hereby certify that the statements contained herein are true and correct and I hereby authorize SCE Partners LLC its subsidaries affiliates and agents to provide to me a win/loss statement of my gaming activity derived from the above referenced account. We do not provide current year statements. I do hereby certify that the statements contained herein are true and correct and I hereby authorize SCE Partners LLC its subsidaries affiliates and agents to provide to me a win/loss statement of my gaming activity derived from the above referenced account. I agree to indemnify and hold harmless SCE Partners LLC and its respective past and present agents employees managers representatives officers directors successors and affiliated persons organizations and companies from any and all suits causes of action liabilities costs losses damages attorney s fees and expenses which I or my administrators executors agents assignees or any third party may have arising out of or relating to this request as a result of this request. .

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