Gaming Distribution Withholding Form

Name(Required)

First Middle Initial Last

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.

Under 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