Empire Casino Win Loss Statement Form – Fill Out and Use This PDF

Empire Card

2012 Win / Loss Statement Request Form

We mail to address on file

Name:	Empire Card Account Number:
Social Security Number:	Date of Birth:
Mailing Address:
City/State/Zip:

I do hereby certify the above information to be true and correct and I hereby authorize Empire City, its Affiliates and Agents to provide to me a Win/Loss Statement of my gaming activity derived from my Empire Card Account.

_________________________	__________________
Account Holder’s Signature	Date

Please bring this form to the Empire City Promotions Booth

Other methods to request a statement:

MAIL

Win/Loss Department

2012 Win/Loss Request

Empire City Casino at Yonkers Raceway

810 Yonkers Avenue

Yonkers, NY 10704

Fax: 914.457.2419

For any questions or comments please call 914.457.2515 or winloss@yonkersraceway.com

DO NOT WRITE BELOW THE LINE. EMPIRE CITY USE ONLY.

Date Received:	Date Mailed:
Statement Year:	Completed By:

810 YONKERS AVENUE  YONKERS, NY 10704  PH: 914.968.4200  FAX: 914.457.2419