Jane Doe authorize Choctaw Casinos to provide me with the above checked statement s.

1210 Durant OK 74701 I hereby certify that the information and statements contained herein are true and correct. All requests must be sent to Choctaw Nation of Oklahoma Finance Department Attn Stacey Workman P. Box Apartment Number City State Telephone Zip E-Mail if applicable Please provide me with a statement of my activity for the tax year s The following document s Please Check Win/Loss Statement W2G 1099 s can be requested after February 1st for the previous tax year. I agree to indemnify administrators executors agents assignees or any third party may have arising out of or relating to this request. By signing below I agree to release Choctaw Casinos its officers directors associates and agents from any loss cost expense including attorney s fees and costs damages liability or claims of any kind.

Please Return form to Choctaw Casino Attention Cage Accounting 3400 Choctaw Rd Pocola Ok 74902 Phone 91 Fax 91 Win/Loss or Tax Information Request Form Name / Players Club Card Last Name First Name Social Security Number Date of Birth Month Mailing Address Day Year Street Address or P.

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