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

Win/Loss Statements are available to Fun Club Members. In order for Oneida Casino to process a Win/Loss Statement, this Request Form is required. This form must be completed and signed by the Fun Club Member requesting the information. A Win/Loss Statement will be returned to the Fun Club Member by mail. Please allow 7 days (14 days during tax time) to process your request. Thank you.

PLEASE PRINT WHEN COMPLETING THIS FORM.
______________________________
Tax Year Requested
___________________________________________	_____________________________________________
Name	Players Club Acct. #

_____________________________________________________________________________________________

Street Address	City	State	Zip
______________________________________	___________________________________________________
Date of Birth		Email
______________________________________	____________________________________
Phone #	Fax #
______________________________________________________________			_____________________
Customer Signature			Date

_____________________________________________________________________________________________

Drivers License # or Social Security # (Must provide DL# or SS# for verification process)

______________________________________________________________		_____________________
	Players Club Employee verifying information	Date
Mail to:	Oneida Casino/Fun Club
	PO Box 365
	Oneida, WI 54155

Disclaimer: Gaming losses in any year may be deducted on your taxes to the extent of reporting winnings in that year. The burden of substantiating losses is upon the customer/player. This statement is provided to assist the customer/player in substantiating losses.

The Oneida Tribe of Indians of Wisconsin and its Bingo and Casino operations, assumes no liability with regard to the accuracy of the customer/player’s losses, the identity of the person using the card, or any other aspect of this statement. The responsibility of substantiating any losses rests with the individual taxpayer. The Internal Revenue Service (IRS) may require additional documentation from the taxpayer when losses are claimed. Please review the appropriate IRS regulations and consult with a competent professional when preparing tax returns (26 USC sec. 6001; Proc 77-29)