Gaming Activity Report W2-G Request Form - Ameristar ...
GAMING ACTIVITY REPORT & W2-G REQUEST FORM Please print all information clearly.
____________________________________________________________________________
First Name
Middle
Last Name
____________________________________________________________________________
Street Address
City
State
Zip Code
____________________________________________________________________________
Last 4 Digits of SSN
B Connected Account Number Date of Birth (mm/dd/yyyy)
_________________________________________________________________________
Phone Number
Tax Year(s) Requested
Do you request a gaming activity report? Yes___ No___ Year(s) _____________ Do you request a copy of your W2-G(s)? Yes___ No___ Year(s) _____________
______________________________________________________________________
Acknowledgment
I certify that the statements contained herein are true and correct, and hereby request that Ameristar Casino Hotel Kansas City provide me with the information requested above. I understand that it is my own responsibility to maintain accurate records of play that, the Gaming Activity Report is not an accounting record and is not appropriate for income tax reporting.
______________________________________________________________________
____________________________________________________________________________
Signature (Required)
Date
*Notary
not
required
if
form
is
requested
or
presented
in
person.
State of: ______________________) ) ss
County of: _____________________)
Acknowledged before me on this the _____ day of _____________________, _______
___________________________________ Notary
(Seal)
Please complete the request form and return it to:
Preferred Delivery Method
Ameristar Casino Hotel Kansas City Attn: Gaming Activity Report 3200 North Ameristar Dr. Kansas City, MO 64161 Phone Number: (866) 667-3386
Fax ____________________ Mail ____________________
Please Allow 2-4 Weeks for Processing Your Request.
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