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Get Win And Loss Statement Form

I hereby authorize PlayLV LLC. its Subsidiaries Affiliates and Agents to provide to me a win/loss statement of my gaming activity derived from the above referenced Account s. WIN/LOSS STATEMENT REQUEST FORM Name Account Number s Date of Birth Phone Number Email Address Mailing Address City/State/Zip Is this a change of address Please Circle Yes or No I would like to request a win/loss statement for my gaming activity for the year Please Circle 2008 2009 2010 2011 2012 2013 2014 Must provide copy of valid identification which includes state issued ID drivers license military ID or passport. Signature Date I do hereby certify that the statements contained herein are true and correct to the best of my knowledge. WIN/LOSS STATEMENT REQUEST FORM Name Account Number s Date of Birth Phone Number Email Address Mailing Address City/State/Zip Is this a change of address Please Circle Yes or No I would like to request a win/loss statement for my gaming activity for the year Please Circle 2008 2009 2010 2011 2012 2013 2014 Must provide copy of valid identification which includes state issued ID drivers license military ID or passport. Signature Date I do hereby certify that the statements contained herein are true and correct to the best of my knowledge. I agree to indemnify and hold harmless PlayLV 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. Do not write in this box - for PlayLV use only. Verified On Valid Government Issued Photo Identification Type All Items Verified in Player Tracking Verifier s Signature Barcode. I agree to indemnify and hold harmless PlayLV 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. Do not write in this box - for PlayLV use only. Verified On Valid Government Issued Photo Identification Type All Items Verified in Player Tracking Verifier s Signature Barcode.

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