Self-Exclusion Removal Request

Pursuant to Iowa Code 99D and 99F, as amended in 2017 by SF 442 enacted on July 1, 2017, the Iowa Racing & Gaming Commission will accept a hard copy of the attached form or a submission of the below online form.

A person may revoke the voluntary exclusion only if the person elected to be voluntarily excluded prior to July 1, 2017 AND the person has been voluntarily excluded for a period of at least five years as of the date of this application. Individuals who submit a form prior to the expiration of the five year exclusion will not be eligible for revocation and a new form must be submitted at a later date

NOTE: This revocation only applies to a statewide self-exclusion pursuant to Iowa Code sections 99D.7(23) and 99F.4(22) and does NOT apply to voluntary or involuntary bans or trespass orders at individual casinos or racetracks.

First Name *

Middle Name *

Last Name *

Former Name(s)

Please enter up to 4 former names or aliases below:

Name

Enter only the last 4 digits of your social security number.

SSN * XXX-XX-

Drivers License #

Date of Birth *

Month

Day

Year

Date of Exclusion

Month

Day

Year

Please indicate the approximate date you signed the lifetime self-exclusion at a casino. Please note, lifetime self-exclusions signed after July 1, 2017 are not eligible to be revoked.

E-mail Address *

Address *

City *

State *

Zip Code *

I understand the State and any licensee under chapter 99F or 99D shall not be liable to any person for any claim which may arise from this process. *

I Agree

I understand that revocation of a statewide self-exclusion is NOT effective until this form has been processed, and I receive written notification from the Iowa Racing & Gaming Commission confirming revocation of the statewide self-exclusion. *

I Agree

I understand that information provided on this form will be shared with the Iowa Gaming Association, custodian of the statewide self-exclusion program, and the racing and gaming industry in order to facilitate this revocation. *

I Agree

I certify, under penalty of perjury and pursuant to the laws of the State of Iowa, the first name, last name, date of birth, and last four digits of the Social Security number entered above are my own, and that the above information is true and correct. *

I Agree

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Self-Exclusion Removal Request