Gaming History Win/Loss Request Form

Gaming History Win/Loss
Request Form
Note: Majestic Star Casino is unable to provide current year statements of play until the end of the year. Please do not
complete this form unless it is a request for a previous year’s statement of play.
PLEASE PRINT
Name: ___________________________________________________________________________________
First Name
Middle Initial
Last Name
Address: _________________________________________________________________________________
City: ___________________________________________ State: ____________ ZIP: ___________________
Phone: (________) ________________________________
Date of Birth: _____/_____/_____
MM/DD/YY
Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Majestic Rewards Card Number:_____________________________________________________________
Tax Year(s) Requested: _____________________________________________________________________
I am requesting that Majestic Star Casino, LLC (MSC) provide my historical gaming activities for the year(s) listed and
above. I hereby release and hold harmless MSC and its respective officers, directors, employees and agents from any
and all claims arising from or relating to the release of the above information. MSC makes no warranty or representation,
express or implied, as to accuracy of the information or its effectiveness as proof of win/loss. Valid photo identification
must accompany this form. Forms received via fax must include a copy of valid photo identification.
Player Signature _____________________________________________
Mail or Fax Form to:
Majestic Star Casino, LLC
Finance Department
Date: _____/_____/_____
MM/DD/YY
Gary, Indiana 46406-3000
Fax: 219-401-0849
Please allow two weeks for processing. Statements will be mailed to the address on patron's valid photo identification.
Must be 21. Gambling Problem? Call 1-800-9-WITH-IT.