Downstream Casino Win Loss Form – Fill Out and Use This PDF

Please return form to: Downstream Casino Resort Attention Income Audit 69300 East Nee Road Quapaw, OK 74363

Win/Loss or Tax Information Request Form

Name _____________________________ /_________________ Players Club Card # __________________
Last Name	First Name
Social Security Number ___________________________ Date of Birth _________ / _________ / ________
	Month	Day	Year
Mailing Address _________________________________________________________ / _______________
	Street Address or P.O. Box		Apartment Number
City ____________________________________________ State ___________ Zip ____________________
Telephone _____________________ E‐mail if applicable ________________________________________
Please provide me with a statement of my activity for the tax year: _________

The following document(s): (Please Check):  Win/Loss Statement  W2G  1099 Gaming

I hereby certify that the information and statements contained herein are true and correct. I hereby authorize Downstream Development Authority DBA Downstream Casino Resort to provide me with the above checked statement(s). By signing below, I agree to release Downstream Development Authority DBA Downstream Casino Resort, its officers, directors, employees, and agents from and against any loss, cost, expense (including attorney’s fees and costs), damages, liability or claims of any kind. I agree to indemnify Downstream Development Authority DBA Downstream Casino Resort from and against any and all suits, causes of action, liabilities, costs, losses, damages, and attorney’s fees and costs which I or my spouse, administrators, executors, agents, assignees or any third party may have arising out of or relating to this request.

I have executed this request at ________________________________________ , ______________

CityState

on this _______ day of ___________________ , 20_____.

___________________________________________________

							Guest’s Authorized Signature
				DO NOT WRITE BELOW THIS LINE. FOR DOWNSTREAM CASINO USE ONLY.
	Identification Type			Insert Verification			Verifier’s Signature
	Social Security
	Photo Identification
	Other Identification
	Notarized