Fillable FORM REQUEST FOR 1099 W2G WIN LOSS

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FORM REQUEST FOR 1099 W2G WIN LOSS

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W-2G, FORM 1099, OR WIN/LOSS STATEMENT
REQUEST FORM
In order for the Kiowa Casino to release any information, each guest is required to submit a signed request form for the release
of the information. Only ofcial request forms will be accepted for processing.
This request form should only be used by guests who are Rewards Club members, have utilized their card for play, or have
received a W-2G or Form 1099. The Kiowa Casino does not track play that is not associated with a guest’s Rewards Club
account. For more information regarding claiming and ling of gambling winnings, guests are encouraged to contact the IRS or
their tax advisor.
PLEASE COMPLETE ALL APPLICABLE BLANKS. BOLDED SECTIONS ARE REQUIRED:
By signing below, I, the guest, hereby release the Kiowa Casino, its ofcers, directors, team members and agents from and
against any loss, cost, expense, including attorney’s fees and costs, damages, liability or claims of any kind. Additionally, I, the
guest, hereby agree to indemnify the Kiowa Casino for, from, and against any loss, cost, expense, including attorney’s fees and
costs, damages, liability or claims of any kind related to the release of this information. I, the guest, acknowledge that the
information being provided is based on player tracking information which includes only the play when my Rewards Club card was
connected to the system and may not accurately reect the amount of my actual play since I, the guest, can play when the card is
not connected to the system and is derived from a system that does not verify the identity of the person using the Rewards Club
card and may include estimated amounts to correct error in inputting information.
***A copy of your driver’s license is required to be attached to this form for verication purposes.
Submit to: Kiowa Casino Properties
Attn: Compliance Department
198131 Hwy 36
Devol, Oklahoma 73531
Fax: (
580) 299 - 3273
Email: jyates@kiowacasino.com
Any questions: Call (580) 299-3514
19131 Hwy 36, Devol, OK 73531 KIOWACASINO.COM P: 866.360.4077 F: 580.299.3486
NAME: REWARDS CLUB #:
SOCIAL SECURITY #: DATE OF BIRTH:
MAILING ADDRESS:
CITY/STATE/ZIP:
TELEPHONE #: FAX #: EMAIL:
PLEASE SEND REQUESTED DOCUMENTS BY (CHOOSE ONE): MAIL FAX EMAIL
DOCUMENT(S) REQUESTED: W-2G FORM 1099 WIN/LOSS STATEMENT
GAMING ACTIVITY FOR YEAR(S):
GUEST’S SIGNATURE: DATE:
RED RIVER VERDEN CARNEGIE HOBART
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FORM REQUEST FOR 1099 W2G WIN LOSS

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Completed 25 March 2021

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