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.
© Copyright 2018 AnyForm