River City Casino Win Loss Form PDF Details

QuestionAnswer
Form NameRiver City Casino Win Loss Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesriver city 2018 win loss statement, river city win loss, river w2g, how to obtain a win losee report from river city casiono in st louis mo

Form Preview Example

Please Allow 2 - 4 Weeks for Processing Your Request.

W-2G/WIN-LOSS REQUEST FORM

Please print all information clearly.

First Name

Middle

 

Last Name

 

 

 

 

Street Address

City

State

Zip Code

 

 

Social Security Number (required for W2-G)

Club Account Number Date of Birth (mm/dd/yyyy)

 

 

 

 

Phone Number

Email Address

 

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 River City 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. In consideration of my receipt of this information, I agree to indemnify and hold harmless River City, 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: River City Casino

Attn: Win-Loss Requests

777 River City Casino Blvd.

St. Louis, MO

63125

Fax number:

(314)

754-1906

Phone Number:

(314)

388-7608

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Part no. 1 of completing successors

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Date, Please complete the request form, and Please Allow Weeks for inside successors

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