Note: A separate signed request is required for each Passport Account.

I hereby request that the Prairie Island Indian Community, d/b/a Treasure Island Resort & Casino furnish me with the 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 falsifying my identity is a fraudulent act and is punishable by law.

Primary Name (as shown on Island Passport Card):

For Income Tax Year:

2009 2008 2007 2006 2005 2004

Island Passport Account:

Apartment / Unit No:

Primary Address:

Zip Code:

City:

State:

AL AR AZ AK CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY

Daytime Telephone

E-mail Address