Rock Win Loss Statement Form PDF Details

The Rock Win Loss Statement form serves as a tool for casino patrons to request a detailed account of their gaming outcomes over a specified period, typically excluding the current year. It requires essential information such as the requester's name, contact details, date of birth, and specific casino-related identifiers including their account number. Besides personal and contact information, the form inquires about a potential change of address, ensuring the statement reaches the correct destination. A noteworthy aspect of this process is the requisite for the account holder's signature to authenticate the request, which, if not submitted in person, necessitates notarization to verify the identity of the requester further. Additionally, it underscores the patron's responsibility to indemnify the casino and its affiliates against any liabilities arising from this request, highlighting the legal protective measures taken by the casino. The precision in documenting and verifying the information, including a section solely for casino use to affirm the identification process, reflects the stringent procedures in place to manage such requests. This document not only facilitates a transparent overview of an individual’s gaming activity but also delineates the rigorous steps involved to safeguard both the requester and the casino establishment’s interests.

QuestionAnswer
Form NameRock Win Loss Statement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesrock win loss statement, hard rock cincinnati win loss statement, hard rock win statement, hard rock atlantic city win loss statement

Form Preview Example

 

 

 

 

 

 

WIN/LOSS STATEMENT REQUEST

Name:

 

 

Telephone:

 

Date of Birth:

 

 

Casino:

 

Email Address:

 

 

Account Number:

 

Mailing address:

 

 

 

 

 

 

City/State/Zip:

 

 

 

 

 

 

Is this a change of address?

YES NO (please circle)

Please provide me with a statement of my gaming activity for the year:

2014

2015

(Please Circle. We do not provide current year statements.)

 

 

I do hereby certify that the statements contained herein are true and correct and I hereby authorize SCE Partners, LLC, its subsidaries, affiliates and agents, to provide to me a win/loss statement of my gaming activity derived from the above referenced account. I agree to indemnify and hold harmless SCE Partners, LLC, and its respective past and present agents, employees, managers, representatives, officers, directors, successors and affiliated persons, organizations and companies, from any 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.

ACCOUNT HOLDER'S SIGNATURE IS REQUIRED BELOW

In witness whereof, I have executed this request at

 

 

,

 

 

 

 

 

 

 

 

City

 

State

on the

 

day of

 

, 20

 

 

.

 

 

Account Holder's Signature

If Account Holder does not present request in person, Account Holder’s signature must be notarized. Only Account Holder may receive or request a Win/Loss Statement. Account Holder MUST present valid government issued photo ID acceptable to SCE Partners, LLC, in its sole and absolute discretion.

SUBSCRIBED AND SWORN TO before me the

 

 

day of

, 20

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTARY PUBLIC

COUNTY

 

 

 

 

STATE

 

 

DO NOT WRITE IN THIS BOX - FOR HARD ROCK HOTEL & CASINO SIOUX CITY USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

VALID GOVERNMENT ISSUED

 

 

 

 

INSERT VALID GOVERNMENT ISSUED

 

 

IDENTIFICATION TYPE

 

 

 

 

IDENTIFICATION TYPE VERIFIED

 

 

Notarized

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Valid Photo ID Verified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Verifier's Signature and Date:

 

 

 

 

 

 

 

 

Please present this request to the Backstage Pass Rewards Club Desk at Hard Rock Hotel & Casino Sioux City. If this

request is not presented in person, request must be notarized. Please mail the original request to:

Hard Rock Hotel & Casino Sioux City

Win/Loss Statement Request

111 3rd Street

Sioux City, IA 51101

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