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Get Lumiere Place W-2G/Win-Loss Request Form

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 Lumiere Place provide me with the information requested above. In consideration of my receipt of this information I agree to indemnify and hold harmless Lumiere Place 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 Lumiere Place Casino and Hotels Attn Win-Loss Requests 999 North 2nd Street St. Louis MO 63102 Fax number 314 881-7457 Please Allow 2 - 4 Weeks for Processing Your Request. 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 Lumiere Place 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 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 Lumiere Place 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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