Full name
Email address
Phone number (with country code)
Country of residence
Select your country…
Canada United Kingdom Mexico Japan Germany France China South Korea Australia ————— Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Central African Republic Chad Chile Colombia Comoros Congo (Democratic Republic) Congo (Republic) Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland Gabon Gambia Georgia Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Macedonia Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Other
Where did you win? (casino/track/lottery name, city)
Do you have a Player Card?
Select…
Yes
No
If yes, at which casino(s)? (optional)
Approximate amount withheld (USD)
Select a range…
$25,000–$100,000
$100,000–$500,000
$500,000–$1,000,000
$1,000,000–$2,000,000
$2,000,000–$3,000,000
Over $3 million
Year(s) this occurred
Attach your 1042-S forms (please note this is required for case review)
Attach your W-8 or W-9 (optional)
Anything else you’d like Patrick to know (optional)
How did you hear about us? (optional)
Select…
Google
ChatGPT or other AI assistant
Referral
Blog post
Other