Win Loss Ameristar – Fill Out and Use This PDF

W-2G /WIN-LOSS REQUEST FORM

Please print clearly.

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FIRST NAMEMIDDLELAST

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STREET ADDRESSCITYSTATE ZIP CODE

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SOCIAL SECURITY NUMBERPLAYERS CLUB CARD #

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PLEASE CHECK ONE OR BOTH OF THE FOLLOWING:

Win-Loss Statement: A single page letter showing estimated play activity (wins or losses) based upon observable and/or carded gaming activity.

W-2G Data: If you have won one or more jackpots exceeding $1,200 a report summarizing these winnings is available.

Request Agreement

I certify that the statements contained herein are true and correct, and I hereby request that the Ameristar property indicated below 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 Ameristar Casinos, Inc., its subsidiaries and affiliates (including the Ameristar property indicated below), 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 incur as a result of, or in any way relating to, my receipt and/or use of the information.

SIGNATURE (REQUIRED) TODAY’S DATE

If the Account Holder does not present this request in person, the Account Holder’s signature must be notarized.

SUBSCRIBED AND SWORN TO before me

the ______ day of ____________________, 20_____.

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NOTARY PUBLIC

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AMERISTAR CASINO BLACK HAWK – CONFIDENTIAL