Form 5754

OMB No. 1545-0239

Statement by Person(s) Receiving Gambling Winnings

(Rev. December 2008)

© Payers of gambling winnings should see the separate Instructions for Forms W-2G

and 5754.

Department of the Treasury

Internal Revenue Service

Date won Type of winnings Game number Machine number Race number

Person to Whom Winnings Are Paid

Name Address

Federal income tax

withheld

Taxpayer identification number Other I.D. Amount received

Persons to Whom Winnings Are Taxable (continued on page 2)

(e) Winnings from

identical wagers

(b) Taxpayer

identification number (a) Name (c) Address (d) Amount won

Under penalties of perjury, I declare that, to the best of my knowledge and belief, the names, addresses, and taxpayer identification numbers that I have furnished correctly

identify me as the recipient of this payment and correctly identify each person entitled to any part of this payment and any payments from identical wagers.

Signature © Date ©

Cat. No. 12100R Form 5754 (Rev. 12-2008)

Part I

Part II

© Recipients of gambling winnings should see the instructions on the back of this form.

For Paperwork Reduction Act Notice, see back of form.

Return to payer. Do not

send to the IRS.
Form 5754 (Rev. 12-2008) Page 2

Persons to Whom Winnings Are Taxable (continued from page 1)

(e) Winnings from

identical wagers

(b) Taxpayer

identification number (a) Name (c) Address (d) Amount won

Purpose of form. You must complete Form 5754 if you

receive gambling winnings either for someone else or as

a member of a group of two or more people sharing the

winnings, such as by sharing the same winning ticket.

The information you provide on the form enables the

payer of the winnings to prepare Form W-2G, Certain

Gambling Winnings, for each winner to show the winnings

taxable to each.

Complete Part II to identify each winner and each

winner’s share of the winnings. If you are also one of the

winners, enter your information first in Part II by entering

“Same as above” in columns (a), (b), and (c) and the

applicable amounts in columns (d) and (e). Then complete

columns (a) through (e) for each of the other winners.

Return the form to the payer.

Taxpayer identification number. The taxpayer

identification number for an individual is the social

security number or individual taxpayer identification

number. For all others, it is the employer identification

number.

Completing the form. If you are the person to whom

gambling winnings are paid, enter your name, address,

and taxpayer identification number in Part I. If the

winnings are from state-conducted lotteries, the box

labeled “Other I.D.” may be left blank. The total amount

received and the total federal income tax withheld must

be entered in the remaining columns.

Signature. If federal income tax is withheld, the person

who receives the winnings must sign and date the form. If

no federal income tax is withheld, no signature is

required.

Paperwork Reduction Act Notice. We ask for the

information on this form to carry out the Internal Revenue

laws of the United States. You are required to give us the

information. We need it to ensure that you are complying

with these laws and to allow us to figure and collect the

right amount of tax. Regulations section 31.3402(q)

requires you to furnish an information return to the payer

if you receive gambling winnings either for someone else

or as a member of a group of two or more people sharing

the winnings, such as by sharing the same winning ticket.

The time needed to complete this form will vary

depending on individual circumstances. The estimated

average time is 12 minutes.

If you have comments concerning the accuracy of this

time estimate or suggestions for making this form

simpler, we would be happy to hear from you. You can

write to the Internal Revenue Service, Tax Products

Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111

Constitution Avenue, NW, IR-6526, Washington, DC

20224. Do not send this form to this address. Instead,

return it to the payer.

Part II

Instructions for Recipient of Gambling

Winnings

You are not required to provide the information

requested on a form that is subject to the Paperwork

Reduction Act unless the form displays a valid OMB

control number. Books or records relating to a form or its

instructions must be retained as long as their contents

may become material in the administration of any Internal

Revenue law. Generally, tax returns and return

information are confidential, as required by section 6103.

Form 5754 (Rev. 12-2008)