Gaming Distribution Withholding Form Download Form Name(Required) First Middle Initial Last Email Last 4 SSN(Required) Withholding federal, state, or both?(Required) Federal State Both Federal(Required) Please enter the amount or percentage to be withheld from federal per cap.State(Required) Please enter the amount or percentage to be withheld from state per cap.If you wish to cancel your withholdings from you revenue shares please check the box below. I wish to cancel all withholdingsUnder penalties of perjury, I declare that I have examined this form and to the best of my knowledge and belief, it is true, correct and complete.Signature(Required)Date Month Day Year