Please Return this Form to Pala Casino Spa Resort Attn Regulatory Compliance Department at the address above This form may also be FAXED to 7. Signatures can and will be verified prior to the release of any W 2G information* If discrepancies are identified PCSR has the right to require additional validation information from the requestor. The signature above releases PCSR from all liability. Pala Casino Spa Resort PCSR will not be held responsible for misdirected W 2G reports. All information will be mailed e mailed or faxed to Print Name Last 4 digits of SSN Address City State Birth Date Privilege Player No Zip Phone Fax Date Signature Requested Information Please check Win/Loss Statement Specify year W2G Report Specify year Please allow up to 10 business days to process. Information will not be provided over the phone. This form will serve as a waiver for the release of information only to the person and address listed below for a period of one year from the date of signature.

Please complete the lower portion of this document including information to be released address to send the information to signature and date.

We will not provide information to you on a spouse family member relative friend or other account without written approval from the holder of that account. Pala Casino Spa Resort PMB 40 35008 Pala Temecula Road Pala CA 92059 Delivery Options Mail Email Pick-up Faxed Dear Sir or Madam As required by Federal legislation as well as considering our guests best interest prior to releasing any financial information we must receive written approval from the owner of the account which we maintain* This letter will serve to fulfill that requirement allowing us to send in written form the information requested by you on your account.

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