Special Tax Return and Application
rom 11-0

i —! i OMB No. 1545-0236
(oe march 1984) for Registry—Wagering cuonec3.31-27
Department of the Treasury Return for period from to June 30,19 _____ XpIres. '
Internal Revenue Service (Month, day, andyear)
Name ‘Social security number
Use IRS label. |" Number and street
please print or Employer identification number
: City, county, state, and ZIP code (See instruction 1)

Check one: H First return and application (Renewal return and application For Internal Revenue Use Only
Supplemental return and application stem ’
Business address number P
Date anne renee ene n eee eea ne

issued _ D>

Alias, style, or trade name, if any

1. If this isa supplemental application, please explain and give your special tax stamp number
and employer identification number. (See instruction 2(b).) >

Compute tax as explained
in instruction 4, and enter
amountduehere. | | p/¢
Make check or money order payable to the

Internal Revenue Service for the amount of tax
due and remit with return.

!f additional space is required for items 2, 3(a), 3(c), or 4, attach additional sheets identifying each entry as to item number.

2. Iftaxpayer is a firm, partnership, or corporation, give true name of members or officers.
True name Title Home address Social security number

3 Are you or will you be engaged in the business of accepting wagers on your own account? wee eee ee. LD ¥es FNo
If “Yes,” complete (a), (b), and (c) of this item.
(a) Name and address where each such business is or will be conducted.

Name of location Address (Number and street) City, state, and ZIP code

(b) Number of employees and/or agents engaged in receiving wagers on your behalf >
(c) True name, special stamp number, address, and social security number of each such person.
True name Special stamp no. Address Social security number

4 Doyou receive or will you be receiving wagers on behalf of or as agent for some other person or persons? . 2. L1Yes C1 No
If “Yes,” give true name, address, and social security number of each such person.
True name Address Social security number

Signature and Verification

Under penalties of perjury, | declare that this return and/or application (including any accompanying statements or lists) has been examined by me and to the best of my
knowledge and belief is true, correct, and complete.

Signature Title (Owner, etc.) > Date >
For Paperwork Reduction Act Notice, see back of form. Form 11-C (Rev. 3-84)



Instructions

(Section references are to the Internal Revenue
Code, unless otherwise noted.)

Paperwork Reduction Act Notice.—
We ask for this information to carry out the
Internal Revenue laws of the United States.
We need it to ensure that taxpayers are
complying with these laws and to allow us to
figure and collect the right amount of tax.
You are required to give us this information.

1. Who Must File.—f you are liable for
the excise tax imposed by section 4401, or
if you are engaged in receiving wagers for or
on behalf of any person so liable, you are
subject to a special tax of $500 per year
imposed by section 4411, and must file
Form 11-C. The rate is $50 per year only if
all wagers are authorized under the law of
the state in which accepted.

In addition, you must file Form 730, Tax
on Wagering, each month to pay and report
the tax on wagers.

Section 4421 defines the term ‘‘wager’’
to mean (1) any wager with respect toa
sports event or a contest placed witha
person engaged in the business of
accepting such wagers, (2) any wager
placed in a wagering pool with respect toa
sports event or a contest, if such pool is
conducted for profit, and (3) any wager
placed in a lottery conducted for profit.

The term ‘‘lottery” includes the numbers
game, policy, punchboards, and similar
types of wagering. The term does not
include: (A) any game of a type in which
usually (1) the wagers are placed, (2) the
winners are determined, and (3) the
distribution of prizes or other property is
made, in the presence of all persons placing
wagers in such game; and (B) any drawing
conducted by an organization exempt from
tax under sections 501 and 521, if no part
of the net proceeds derived from such
drawing inures to the benefit of any private
shareholder or individual.

if you are required to file Form 11-C and
have not applied for an employer
identification number, please complete
Form SS-4, Application for Employer
Identification Number, and attach it to your
return when you file. If you have applied for
a number but have not received notice of it
by the time you must file, please write
“Number applied for’’ in the block on the
form for the number.

2. When to File.—

(a) First and Renewal Returns and
Applications for Registry.—Form 11-C
serves two purposes: (A) a special tax return
and (B) an application for registry. You must
file the first return and application for
registry before engaging in the activity in
which you become liable for the special tax
on wagering. You must file renewal returns
and applications by July 1 of each year
thereafter during which taxable activity
continues. Changes in ownership which
require a return and application for registry,
and which result in special tax liability,
include the following:

(1) Admission of new members to a firm
or partnership.

(2) Formation of a corporation to
continue the business of a partnership.

(3) Continuance of the corporate
business by a stockholder after the
corporation is dissolved.

(b) Supplemental Applications for
Registry.—If you have a change of place of
business or residence address, you must be
registered by filing a Form 11-C, checking
the block designated ‘‘Supplemental return
and application,”’ and giving the new ad-
dress and the date of change before: (1)
you engage in any wagering activity at the
new address, or (2) the termination of a
30-day period which begins on the day after
the date of such change, whichever occurs

irst.

Any other change must also be
registered within 30 days after such
change. Examples of other changes include
the following: (1) continuance of the
operation of a business of a deceased
person, who has paid the special tax, by the
surviving spouse or child, or executor or
administrator, or other legal representative,
(2) continuance of a business by a receiver
or trustee in bankruptcy, (3) continuance of
a business by an assignee for the benefit of
creditors, (4) withdrawal from a firm or
partnership of one or more members, and
(5) mere change of corporate name. Failure
to comply with these requirements will
result in additional tax and penalty. The
taxpayer's special tax stamp must
accompany such supplemental
application for proper notation.

Not later than 10 days after engaging a
new agent or employee to receive wagers,
an individual accepting wagers on his or her
own account shall register the name,
number appearing on the special tax stamp,
address, and social security number of each
such agent or employee by filing a Form
11-C designated ‘Supplemental Return.”
Likewise, an agent or employee receiving
wagers on behalf of another must register
the name, address, and social security
number of each additional person by whom
he or she is engaged to receive wagers
within 10 days after being so engaged.

3(a). Where to File.-—

If your principal business, ‘Send your return to
office or agency, or legal Internal Revenue
residence in the case of an Service Center at this
individual, is located in address
v v
New Jersey, New York City
and counties of Nassau,
Rockland, Suffolk, and Holtsville, NY 00501
Westchester
New York (all other. tt
Counties) Connecticut,
Maine, Massachusetts” Andover, MA 05501

New Hampshire, Rhode
Island, Vermont

Delaware, District of
Columbia, Maryland,
Pennsylvania

Alabama, Florida,
Georgia, Mississippi,
South Carolina

Michigan, Ohio

Arkansas, Kansas,
Louisiana, New Mexico,
Oklahoma, Texas

Alaska, Arizona, Colorado,
Idaho, Minnesota, Montana,
Nebraska, Nevada, North
Dakota, Oregon, South
Dakota, Utah, Washington,
Wyoming

iMinois, lowa,

Missouri, Wisconsin
California, Hawaii

indiana, Kentucky,

North Carolina, Tennessee,
Virginia, West Virginia

Philadelphia, PA 19255.

Atlanta, GA 31101

Cincinnati, OH 45999

Austin, TX 73301

Ogden, UT 84201

Kansas City, MO 64999
Fresno, CA 93888

Memphis, TN 37501

If you have no legal residence, principal
place of business or principal office or
agency in any Internal Revenue district, file
your return with the Internal Revenue
Service Center, Philadelphia, PA 19255.

(b) Hand-Carried Returns.—Returns
that are filed by hand-carrying (as defined in
Regulations section 301.6091-1(c)) shall
be filed with the District Director or with any
permanent post of duty within that Internal
Revenue district.

4. Computation of the Special Tax on
Wagering.—Special tax liability is
computed from July 1 of each year, or the
first day of the month during which you
began the business, to the following June
30. For a renewal or for a business begun
during July, the tax is $500. If you begin
business after the month of July, compute
the tax to be remitted by multiplying the
monthly rate of $41.66% by the number of
months remaining in the fiscal year.
Example: If you began the business in
November, compute liability as follows:
$41.66% X 8 (the number of months
remaining in the fiscal year) equals
$333.33, the amount to be remitted. Enter
the amount of tax in the designated block
on the return. Since the tax is only $50
when wagering is authorized under state
law, use 10% of the above figures to
illustrate the liability.

5. Penalties.—If you do not file the
return before engaging in the activity in
which you become liable for the
occupational tax on wagering, you may
incur the penalties prescribed by sections
6651 and 6653. In addition, under the
provisions of section 7262, if you perform
any act that makes you liable for the special
tax, without having paid such tax, you will
incur a fine of not less than $1,000 and not
more than $5,000. For willful failure to file
areturn or pay the tax, the penalties under
sections 7201 and 7203 may be imposed.
For making and subscribing a false return,
statement or other document under the
penalties of perjury, or aiding or advising
the preparation of such returns, statements
or other documents, the penalties under
sections 7206(1) and 7206(2) may be
imposed.

Under section 1001 of Title 18, U.S.C.,
whoever knowingly makes any false or
fictitious statement with respect to the
payment of the special tax, such as the
giving of a false name or address, shall be
fined not more than $10,000 or imprisoned
not more than 5 years, or both.

6. Disclosure of Wagering Tax
Information.—No Treasury Department
official or employee may disclose, except in
connection with the administration or
enforcement of Internal Revenue taxes, any
document or record supplied by a taxpayer
in connection with such taxes, or any
information obtained through any such
documents or records. Additionally, certain
documents related to wagering taxes, and
information obtained through such
documents, may not be used against the
taxpayer in any criminal proceeding, except
in connection with the administration or
enforcement of Internal Revenue taxes. See
section 4424 for more detailed information.