Request Win / Loss Statement

I hereby certify that the information and statements contained herein are true and correct and I hereby authorize The Black Hawk Casino to provide me the above requested statement.

By completing and sending this form, I agree to release The Black Hawk Casino, it’s officers, directors, employees, and agents from and against any loss, cost, expense (including attorney’s fees and costs) damages, liability, or claims of any kind. I agree to indemnify The Black Hawk Casino from and against all suits, causes of action, liabilities, cost, losses, damages, attorney’s fees and costs which I, or my spouse, administrators, executors, agents, assignees, or of any third party may have arising out of or relating to this request.

Your request will be dated by the timestamp of when you send the form.

Your Full Name:

Date Of Birth (Example: 01/01/1998):

Your Email:

Mailing Address:

Contact Number:

Report Year Requested:

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