Request Your W-2 W2G & WIN/LOSS Statement Request Reports Requested *Select One W2GWIN/LOSS For Income Tax years 2018201920202021 Primary Name (as shown on your Player's Card) Player's Card # Daytime Telephone # Date of Birth Your Email (required) Driver's License # Last four digits of your Social Security Number (XXX-XX-____) Address City State Zip Code I understand that my win/loss statement will include estimated gaming win/loss information. The tracking system used in providing this information is based upon the use of your Players Club Card Information. Therefore, this statement will not reflect an accurate accounting record - it merely provides an estimate you can use to compare to your records.   I do hereby certify that the information contained above is true and correct, and I authorize Derby City Gaming to provide me a win/loss statement of tracked gaming activity for my Players Club account. I further understand that the information requested is generated from a player’s tracking system based upon Rewards Club account history and is not intended to be, or take place of, my own records of my gaming activity. Derby City Gaming makes no representation or warranty, express or implied, as to the accuracy of this information or its effectiveness as proof of winnings and losses.