WIN/LOSS STATEMENT

REQUEST FOR WIN/LOSS STATEMENT

To obtain a statement of your gaming activity, please fill out the form below and attach a scan or photo of your valid photo ID:

Player Extras Card Number
Player Name
Date of Birth – must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Win/Loss Statement For Tax Year(s)
for multiple years, separate requested years by commas
Upload Your Driver's License Photo
I hereby request that Saratoga Casino Black Hawk provide my historical gaming activities for the year(s) listed above.
Signature
PLEASE NOTE: Photo or scan of your valid photo ID is required for online request submissions. To protect the privacy of our players, we will not process requests without an attachment of a photo ID. You may also print and fill out the official request form and mail it along with a photocopy of your ID to: Saratoga Casino Black Hawk, Attention Marketing, P.O. Box 427, Black Hawk, CO 80422. Statements can be picked up in person at Guest Services, e-mailed to you, or mailed to your home address. Valid photo ID is required for all requests, regardless of delivery method.
Phone
This field is for validation purposes and should be left unchanged.