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Get SMSC Gaming Enterprise Request for Win/Loss/Documentation 2009

Request for Win/Loss/Documentation for personal income tax filing Please complete the following information. Failure to complete this form accurately and legibly may delay our ability to furnish the requested information. Primary Name As shown on Club Mystic card Club Mystic Account Number Primary Address Include Street Address Apartment/Unit No. City State and Zip Code For Income Year List the year s that you are requesting such information for Daytime Telephone Number 10 digit number By executing this document below I hereby request that the SMSC Gaming Enterprise Mystic Lake Casino Hotel MLCH /Little Six Casino LSC owned and operated by the Shakopee Mdewakanton Sioux Community SMSC furnish me with the requested estimated tracked win/loss/documentation for my personal use. I hereby hold the SMSC Community and the SMSC Gaming Enterprise MLCH/LSC harmless of any errors that may be contained within the requested document I also understand that the figures contained within the requested document may not be indicative of my complete gaming win and/or loss and is only that of which is recorded while utilizing my personal Club Mystic card. identity is a fraudulent act and is punishable by law. Signature Primary Account Holder The SMSC Gaming Enterprise is not responsible for the accuracy of this estimate. Consult your tax advisor if you have questions regarding deducting gaming losses on your tax return* Note A separate signed request is required for each Club Mystic account. The requested information will be mailed to the address on file unless legally required to send to another address. I hereby hold the SMSC Community and the SMSC Gaming Enterprise MLCH/LSC harmless of any errors that may be contained within the requested document I also understand that the figures contained within the requested document may not be indicative of my complete gaming win and/or loss and is only that of which is recorded while utilizing my personal Club Mystic card. identity is a fraudulent act and is punishable by law. Signature Primary Account Holder The SMSC Gaming Enterprise is not responsible for the accuracy of this estimate. identity is a fraudulent act and is punishable by law. Signature Primary Account Holder The SMSC Gaming Enterprise is not responsible for the accuracy of this estimate. Consult your tax advisor if you have questions regarding deducting gaming losses on your tax return* Note A separate signed request is required for each Club Mystic account. Consult your tax advisor if you have questions regarding deducting gaming losses on your tax return* Note A separate signed request is required for each Club Mystic account. The requested information will be mailed to the address on file unless legally required to send to another address. I hereby hold the SMSC Community and the SMSC Gaming Enterprise MLCH/LSC harmless of any errors that may be contained within the requested document I also understand that the figures contained within the requested document may not be indicative of my complete gaming win and/or loss and is only that of which is recorded while utilizing my personal Club Mystic card. identity is a fraudulent act and is punishable by law. Signature Primary Account Holder The SMSC Gaming Enterprise is not responsible for the accuracy of this estimate. Consult your tax advisor if you have questions regarding deducting gaming losses on your tax return* Note A separate signed request is required for each Club Mystic account. .

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