Win/Loss Request - The Rose Gaming Resort

Win/Loss Request Form

Please complete all of the following fields to request a Win / Loss statement from The Rose Gaming Resort. Please include a copy of your ID with this request. Allow 2-4 weeks for processing your request. You may also submit a written request containing all of the information required in this form to: The Rose Gaming Resort, ATTN: WIN/LOSS STATEMENT, 10515 Colonial Downs Parkway, New Kent, VA 23124.

Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Account Number(Required)

Date of Birth(Required)

Players Card Photo Upload

Accepted file types: jpg, png, Max. file size: 50 MB.

Photo ID Photo Upload(Required)

Accepted file types: jpg, png, Max. file size: 50 MB.

Phone Number(Required)

Tax Years Requested(Required)

Acknowledgement:(Required)

By submitting this form, I certify that the information and statements provided herein are true and correct. I hereby request and authorize The Rose Gaming Resort to provide me with a Win/Loss statement of tracked gaming activity for my Rosie’s Rewards membership. I understand that the information requested is generated from a rewards tracking system based upon Rosie’s Rewards account history based upon the terms and conditions and use of my Rosie’s Reward card. I acknowledge that is my own responsibility to maintain accurate records of my gaming activity and the Win/Loss statement is not intended to be, or take place of, my own records of my gaming activity for any reason. I understand that a Win/Loss statement is not a tax document and is not a substitute for records required of me for applicable State or Federal tax laws. The Win/Loss statement will not reflect an accurate accounting record as it merely provides an unverified, estimate for comparison to my records. By submitting this form, I acknowledge that The Rose Gaming Resort shall not be responsible if I do not receive the requested information and, further, that The Rose Gaming Resort makes no representation or warranty, expressed or implied, as to the accuracy of this information or its effectiveness as proof of winnings and losses. In the event that the information provided by you has changed or no longer matches the information on file, we may be unable to satisfy your request. Please contact The Rose Gaming Resort if you need to change your information.

Signature (print)(Required)

Signature(Required)

Date(Required)

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