Win/Loss & W2G Requests Previous Slide Next Slide WIN/LOSS STATEMENTS AND W2G REQUESTS If you have won a taxable jackpot during the year, you were given Form W2G-1099 at the time you won the jackpot. You may request a copy here. Request Your Statement Win/Loss or W2G Request Form Please Select the Document(s) You are Requesting(Required) Win/Loss Statement W2G Year(Required) 2024 2023 2022 Full Name(Required)Player's Card Number(Required)Birth Date(Required) MM slash DD slash YYYY Email(Required) Phone Number(Required)Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code All requested forms can only be mailed to the contact information we have on file. If any changes are necessary, you will be contacted to come to the casino with your valid state issued photo ID to update your information.CommentsAcknowledgment(Required) By submitting a request for either a Win/Loss statement or W2G, you acknowledge that Derby City Gaming shall not be responsible if you do not receive the requested information. 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 Derby City Gaming if you need to change your information. WIN/LOSS REQUEST This is not a tax document. By submitting this form you acknowledge and agree that you are requesting a Win/Loss Statement that will include estimated gaming Win/Loss information. The tracking system used in providing this information is based upon the terms and conditions and use of your Players Club card. Therefore, this statement will not reflect an accurate accounting record - it merely provides an unverified, estimate for comparison to your records. This is not a substitute for records required by you for applicable State or Federal tax laws. Furthermore, by submitting this form, you certify that the information inputted above is true and correct, and authorize Derby City Gaming to provide a Win/Loss Statement of tracked gaming activity for your Players Club membership. You further understand that the information requested is generated from a guest's tracking system based upon Players Club account history and is not intended to be, or take placed of, your own records of your gaming activity. Derby City Gaming makes no representation or warranty, expressed or implied, as to the accuracy of this information or its effectiveness as proof of winnings and losses. W2G REQUEST A request for W2Gs is a request for copies of all IRS form W-2G/1099s issued to you. This is not a request for a complete accounting of your play. For additional information on the Form W-2G and its instructions, visit www.irs.gov/FormW2GCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.