Gaming Promotions Entertainment Lodging Locations Careers Club Wild REQUEST WIN/LOSS STATEMENT Request your win/ loss statement by filling out the form and selecting all properties that apply. A team member will reach out to you if more information is needed. Thank you! First Name Last Name Email Address Re-print form W2G Phone Number Mailing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Date of birth Player club number Year/s requested Properties Emmetsburg Clinton Jefferson By signing below, I request and authorize Wild Rose Emmetsburg, LLC (“WRE”), Wild Rose Clinton LLC ("WRC") and Wild Rose Jefferson, LLC ("WRJ") to release to me a gaming history report containing data contained in the player tracking system; I release, acquit and discharge WRE, WRC, WRJ, its officers, directors, agents, assigns and employees, from any liability arising out of the release of this information to me and/or out of my use of the information; and I further agree to indemnify, hold harmless and defend WRE, WRC, WRJ, its officers, directors, agents, assigns, insurers and employees, from any and all actual or potential claims by third parties from the release of this information or its use by me or on my behalf or by any other persons or agencies to whom I provide the information. I understand that WRE, WRC, and WRJ cannot verify the completeness or accuracy of the information in the system for my tax purposes, makes no representation, commitment, or guarantee that the information released is complete or accurate for tax purposes, or that it will be accepted by the Internal Revenue Service or other taxing authority, or that the amounts shown as losses will be deductible or excludable from my gross income for federal or state income tax purposes, or that any specific federal or state tax treatment will apply to or be available for me. I understand that it shall be my obligation to determine what amounts are deductible or excludable form my gross income for federal or state income tax purposes, and to notify WRE, WRC, WRJ if I have reason to believe that any information released to me is inaccurate. Today's date Signature Your browser does not support the Signature field Clear Submit CLUB WILD Unlock all the exclusive benefits and rewards of Club Wild by joining. Membership is free and it is easy to join. Visit a Club Wild Representative on your next visit to enroll. New Club Wild members will receive 2,000 bonus points just for signing up! That's $5 in Free Play! Get even more rewards the day you sign up simply by earning points when you play using your Club Wild card. Learn More Careers at Wild RoseWin/Loss Statements Corporate Office 5465 Mills Civic Parkway #400 West Des Moines, IA 50266 515-248-1776 Clinton 777 Wild Rose Drive Clinton, IA 52732 563-243-9000 Emmetsburg 777 Main Street Emmetsburg, IA 50536 712-852-3400 Jefferson 777 Wild Rose Drive Jefferson, IA 50129 515-386-7777 ©2021 Wild Rose Casino & Resort. All Rights Reserved Privacy PolicyTerms and Conditions If you or someone you know needs gambling treatment, visit 1800BetsOff.org