Plainridge Win Line Deposit / Withdrawal Slip

Name:

___________________________ _____________________________

Last First Deposit $______________

___________________________ _____________________________

Address City

Withdrawal $_____________

___________________________ _____________________________

State Zip

___________________________

Account #

_________________________________________________________________ ________________________

Signature Date

Plainridge Win Line Deposit / Withdrawal Slip

Name:

___________________________ _____________________________

Last First Deposit $______________

___________________________ _____________________________

Address City

Withdrawal $_____________

___________________________ _____________________________

State Zip

___________________________

Account #

_________________________________________________________________ ________________________

Signature Date