Win Loss Report(s) Request

Please fill out this form completely.
Your report(s) will be available to pick up 7–10 working days after the date you submit your request.
When picking up your report(s), you must present a valid photo ID matching the name of the requestor.

Time Frame Requested *

Type of Report(s) *

Summary

Daily Detailed

Name *

Address *

Phone Number *

Email Address

Rewards Club Membership Number *

Terms of Acceptance and Signature *

I do hereby certify that the information contained herein is true and correct and I am the account holder and have the right to receive the information requested. I hereby authorize Forest County Potawatomi Community d/b/a Potawatomi Bingo Casino (PBC) to provide me with my Win/Loss Statement(s) based on my Fire Keeper’s Club/Potawatomi Rewards Club records. In consideration for this information, I hereby release and hold harmless, Forest County Potawatomi Community, PBC, and all of their respective elected and appointed officials, officers, directors, employees, representatives and agents (hereinafter collectively referred to as the “Released Parties”) from any and all claims arising from or relating to the information or its release, and further agree to hold harmless and fully indemnify the Released Parties from any such claims.

I understand that the information generated from an internal marketing system is not an “official record” and does not take the place of my own gaming activity records. I further understand that the Tribe makes no representation or warranty, express or implied, of the accuracy of the information or its effectiveness as proof of wins or losses.

Signature (type your full name) *

Date *

Please note that gaming losses in any year may be deducted on your taxes to the extent of gaming winnings are reported in the same year. Please review the appropriate Internal Revenue Service regulations and consult with a competent tax professional when preparing your tax return.