Request for Win/Loss Documentation for Personal Income Tax Filing
Slot Play Only.

Please note: A win/loss statement is documented based on recorded and rated play while utilizing your
Club Horizon Players Club Card only and may not be indicative of a person's complete and true win/loss in
regards to gaming. Information contained within this report is recorded slot play and does not indicate any rated table
games play regardless of personal ratings.

Please complete the following information. All fields are mandatory. Failure to complete this form accurately and legibly
may delay our response to completing your request

Please allow 3-4 Business Days to process your request

Name as presented on Club Horizon Players Card: *
Club Horizon Players Card Number: *
Year *	Please enter the year for which you would like your Win/Loss report. Enter as yyyy Example 2009
Street Address: *
City: *
State: *	AL AK AR CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip: *
Primary Account Signature: *
Please mail me my win/loss report	x
I will pick-up my win/loss report	x
Email Address (only if you would like the report emailed):
Image Verification Please enter the text from the image: [Refresh Image] [What's This?]