Video Gaming Terminal (VGT) Patron Dispute/Complaint Form

Questions or comments regarding patron disputes or complaints can be directed to the Pennsylvania Gaming Control Board at

Name of individual filing a
dispute or complaint:
Home Address:
City, State, Postal Code:
E-mail Address:
Date and Approx Time of Incident:
Location of VGT Establishment Where Incident Occurred:
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 entity's personnel or any statements you made to witnesses to the incident or dispute.
By submitting this patron complaint/dispute form, I understand that I am making a request for an investigation of this matter by the Pennsylvania Gaming Control Board 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 the penalties for violations of 4 Pa.C.S. §1518(a)(1), relating to perjury, false swearing and unsworn falsifications.
58 Pa.Code §461.4(n) provides that if a dispute arises with a patron concerning payment of alleged winnings, the slot machine licensee shall notify the patron in writing, concurrent with its initial receipt of notice of the dispute, that the patron has the right to contact the Board with regard to the dispute.

58 Pa.Code §461.4(o) provides that when a slot machine licensee refuses to pay winnings claimed by a patron and the patron and the slot machine licensee remain unable to resolve the dispute after seven (7) days, the slot machine licensee shall, on the next day, notify the Board in writing of the dispute in a manner and form the Board prescribes. The notice must identify all parties to the dispute and shall state all known relevant facts regarding the dispute.
This form is for Video Gaming Terminals located at PA Truck Stops. This form should not be used for Games of Skill, Computer, Tablet, or Phone Gaming Applications.

 Click here to access the form.