Free 51676.pdf - Indiana

INDIANA GAMING COMMISSION PATRON COMPLAINT FORM
State Form 51676 (3-04)

(PLEASE PRINT)

NAME OF PATRON:

STREET ADDRESS: CITY, STATE, ZIP CODE: HOME TELEPHONE: ( ) WORK OR SECONDARY TELEPHONE: ( INCIDENT INFORMATION CASINO WHERE INCIDENT OCCURRED: LOCATION OF INCIDENT: DATE OF INCIDENT: TIME OF INCIDENT: )

COMPLAINT SUMMARIZE THE NATURE OF THE COMPLAINT (ATTACH ADDITIONAL SHEETS, IF NECESSARY)

WITNESS INFORMATION (ATTACH ADDITIONAL SHEETS, IF NECESSARY) IF AVAILABLE, LIST THE NAMES OF CASINO EMPLOYEES WHO WITNESSED OR WERE INVOLVED IN THE INCIDENT
LIST ALL AVAILABLE INFORMATION OF ANY OTHER WITNESS(ES) TO THE INCIDENT

SUMMARIZE THE CASINO'S ATTEMPT TO RESOLVE THE PROBLEM My signature below certifies that the information provided in this document is, to the best of my knowledge, accurate. SIGNATURE: DATE:

This form may be mailed to: Indiana Gaming Commission ·South Tower, Suite 950 ·115 West Washington Street · Indianapolis, IN 46204-3408, submitted to the IGC agents at the vessel where the complaint occurred, or submitted via fax at (317) 233-0047. Please provide the white copy or original to the IGC and retain the yellow copy or a photocopy for your records.