Please specify which year.


I certify that the statements contained herein are true and correct, and hereby request that French Lick Resort provide me with the information requested above. I understand that it is my responsibility to maintain accurate records of play, and that the information I am requesting consists of estimates and may not be appropriate for income tax reporting. In consideration of my receipt of this information, I agree to indemnify and hold harmless French Lick Resort, its subsidiaries and affiliates, and their respective officers, directors, employees, and agents from any and all claims, suits causes of action, liabilities, costs, losses, damages, and expenses (including attorney's fees and costs) which I, or my administrators, executors, agents, successors, heirs or assigns, or any third party, might have or incur as a result of, or in any way relating to, my receipt and/or use of the information. For more information, contact the IRS or see IRS Tax Topic 49 Win-Loss Statement: Document indicates estimated play activity (win or loss) based upon observable and/or carded gaming activity.