SLOT PLAY ONLY

Please note: A win/loss statement is documented based on recorded and rated play while utilizing an Island Passport Club card only and may not be indicative of a persons complete and true win/loss in regards to gaming. Information contained within this report is recorded slot play and does not indicate any rated table games play regardless of personal ratings.

Please complete the following information. All fields are MANDATORY. Failure to complete this form accurately and legibly may delay our response in completing your request.

Primary Name (as shown on Island Passport Card):
First:   Last:

Note: A separate signed request is required for each Passport Account. Joint accounts require two requests and two signatures. Spouses MAY NOT request a win/loss documentation for their respective spouses pursuant to internal privacy policies.

For Income Tax Year:
2003 2004 2005 2006 2007 2008

Island Passport Account:

Primary Address:

Apartment / Unit No.

City: State: Zip:

Daytime Telephone:

E-mail Address:

I hereby request that the Prairie Island Indian Community, d/b/a Treasure Island Resort & Casino furnish me with the above requested recorded information for my personal use. I hereby hold PIIC and TIR&C harmless of any errors that may be contained within the requested document. I also understand that the figures contained within the requested document may not be indicative of my complete gaming win and or loss and is only that of which was recorded while utilizing my personal Island Passport Club card.
By checking this box I verify that I am the primary account holder. I understand that lying about my identity is purgery and is punishable by law.