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Please complete this form sign and send back to us. Tioga Downs Attn Player s Club 2384 W. River Rd. Nichols NY 13812 Or FAX to 607 699-3712 Win/Loss Statement Request for Year Account Date of Request NAME ADDRESS CITY STATE ZIP Acceptable ID Requestors Signature Received by Name and Badge Completed by Name and Badge Date Mailed/Received Acceptable ID Any state or government issued photo identification. Please send a photo copy with request form. Number must be documented.. Please complete this form sign and send back to us. Tioga Downs Attn Player s Club 2384 W* River Rd. Nichols NY 13812 Or FAX to 607 699-3712 Win/Loss Statement Request for Year Account Date of Request NAME ADDRESS CITY STATE ZIP Acceptable ID Requestors Signature Received by Name and Badge Completed by Name and Badge Date Mailed/Received Acceptable ID Any state or government issued photo identification* Please send a photo copy with request form* Number must be documented*.

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