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Get Muckleshoot Casino Win/Loss Statement Request

WIN/LOSS STATEMENT REQUEST PREFERRED PLAYERS CLUB PROGRAM To request a statement of your gaming activity for a calendar year please fill out this form and return to the Preferred Players Club at Muckleshoot Casino. 2812. Name PPC Account Number Social Security Number Date of Birth Mailing Address City/State/Zip Telephone Receipt Preference Please provide me with a statement of my gaming activity for the year Will Pick Up at Players Club Mail to Mailing Address Listed I DO HEREBY CERTIFY THAT THE STATEMENTS CONTAINED HEREIN ARE TRUE AND CORRECT AND I HEREBY AUTHORIZE MUCKLESHOOT INDIAN TRIBE dba MUCKLESHOOT CASINO TO PROVIDE TO ME A WIN/LOSS STATEMENT OF MY GAMING ACTIVITY DERIVED FROM MY PREFERRED PLAYERS CLUB ACCOUNT. You will need valid photo identification along with this completed form in order to process. If you choose to mail in your request or submit your request through a third party the account holder s signature must be notarized* If you have any questions regarding this form you may contact the Preferred Players Club at 800-804-4944 ext. I AGREE TO INDEMNIFY AND HOLD HARMLESS MUCKLESHOOT CASINO AND ITS RESPECTIVE PAST AND PRESENT AGENTS EMPLOYEES MANAGERS REPRESENTATIVES SUCCESSORS AND AFFILIATED PERSONS ORGANIZATIONS AND COMPANIES FROM MY 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. IF ACCOUNT HOLDER DOES NOT PRESENT REQUEST IN PERSON ACCOUNT HOLDER S SIGNATURE MUST BE NOTORIZED Account Holder s Signature Date Affix Notary Seal Here NOTARIZATION Subscribed and sworn to before me this day of 20 Signature of Notary Public Notary Public in and for the County of And the State Of My Commission Expires DO NOT WRITE IN THIS BOX. FOR MUCKLESHOOT CASINO USE ONLY IDENTIFICATION TYPE NOTARIZED PHOTO ID OTHER ID DATE RECEIVED INSERT ID TYPE VERIFIED VERIFIER S SIGNATURE DATE. I AGREE TO INDEMNIFY AND HOLD HARMLESS MUCKLESHOOT CASINO AND ITS RESPECTIVE PAST AND PRESENT AGENTS EMPLOYEES MANAGERS REPRESENTATIVES SUCCESSORS AND AFFILIATED PERSONS ORGANIZATIONS AND COMPANIES FROM MY 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. IF ACCOUNT HOLDER DOES NOT PRESENT REQUEST IN PERSON ACCOUNT HOLDER S SIGNATURE MUST BE NOTORIZED Account Holder s Signature Date Affix Notary Seal Here NOTARIZATION Subscribed and sworn to before me this day of 20 Signature of Notary Public Notary Public in and for the County of And the State Of My Commission Expires DO NOT WRITE IN THIS BOX. IF ACCOUNT HOLDER DOES NOT PRESENT REQUEST IN PERSON ACCOUNT HOLDER S SIGNATURE MUST BE NOTORIZED Account Holder s Signature Date Affix Notary Seal Here NOTARIZATION Subscribed and sworn to before me this day of 20 Signature of Notary Public Notary Public in and for the County of And the State Of My Commission Expires DO NOT WRITE IN THIS BOX. FOR MUCKLESHOOT CASINO USE ONLY IDENTIFICATION TYPE NOTARIZED PHOTO ID OTHER ID DATE RECEIVED INSERT ID TYPE VERIFIED VERIFIER S SIGNATURE DATE. .

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