Casino / Sports Wagering Complaint Form First Name Last Name Address City State Zip Code Phone Number Email Address Date and Approximate Time of Incident Location of Incident —Please choose an option—Hollywood PerryvilleOcean DownsLive! CasinoRocky GapHorseshoeMGMSportsbook If your complaint is about a sportsbook, enter the sportsbook's name here: Has a complaint been previously submitted to a licensed gaming faciltiy about this incident or dispute? YesNo Please provide the date the complaint was submitted Please provide a summary of the incident or dispute to the best of your knowledge. Include any statements which you made to the licensed gaming facility personnel or any statements you made to witnesses about the incident or dispute: If applicable, please provide the following information: Casino Game Table Number Casino Slot Machine Number By submitting this patron complaint/dispute form, I understand that I am making a request for an investigation of this matter by the Maryland Lottery and Gaming Control Agency and declare that all information provided on the pages of this form and on any pages that I attach hereto are true and factual to the best of my knowledge. I further understand that if I have knowingly, intentionally or willfully made false statements or intentional misrepresentations that I may be subject to penalties.
