om MO Special Tax Return and Application see instruct sack
‘orm ee Instructions on bact
(Rev. May 1974) For Registry Wagering for time and place for

Inert Rene Saree” | Return for petiod from. non 419... to June 30, 19 filing return.

y
Check one: (] First return and application {_] Renewal return and application {_] Supplemental return and application

o | True name Employer identification number
— (see instruction 1)
S
Z| Alias, style, or trade name, if any
“1
g Number and street For Internal Revenue Use Only
3 Stamp
4/%| City, County, State and ZIP code pamper >
8 ez issued >
Z|] Number and street
8 TS
“le FF
$| City, County, State and ZIP code FP
2 -
|

3 If this is a supplemental application, please explain and give your Special Tax Stamp T$
Number and employer identification number. (See instruction 2(b).) >. Compute tax as explained

.| in instruction 4, and enter

_| amount due here . . >

Make check or money order payable to the
Internal Revenue Service for the amount
of tax due and remit with return.

If additional space is required for items 4, 5(a), 5(c), or 6, attach additional sheets, identifying each entry as to item number.

4 If taxpayer is a firm, partnership, or corporation, give true name of members or officers.
True name Title Home address

5 Are you or will you be engaged in the business of accepting wagers on your own account? . . . . . - .([] Yes [] No

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 Street address City, State, and ZIP code

(b) Number of employees and/or agents engaged in receiving wagers on your behalf p>...

(c) True name, current address, and Special Tax Stamp Number of each such person.
Special stamp No. in present use Street address ity, State, and ZIP code

True name

6 Do you receive or will you be receiving wagers on behalf of or as agent for some other person or persons? . . [] Yes [] No

If “Yes,” give true name and address of each such person.
True name Street address City, State, and ZIP code

Signature and Verification

| declare under the penalties of periury 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 >
Form 11=C (Rev. 5-74)



Instructions
(References are to the Internal Revenue Code.)

1. Who Must File.—Every person who
is liable for the 10-percent excise tax im-
posed by section 4401, and every per-
son who is engaged in receiving wagers
for or on behalf of any person so liable,
is subject to a special tax of $50 per year
imposed by section 4411, and must file
Form 11-C.

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

Section 4421 defines the term ‘‘wager’’
to mean (1) any wager with respect to
a sports event or a contest placed with
a person engaged in the business of ac-
cepting such wagers, (2) any wager
placed in a wagering pool with respect
to a 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 num-
bers game, policy, 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 con-
ducted 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 ap-
plied 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 Re-
newal Returns and Applications for Reg-
istry—Form 11-C serves two purposes:
(A) A special tax return and (B) an appli-
cation for registry. The first return and
application for registry must be filed prior
to engaging in the activity which results
in liability for the special tax on wagering.
Renewal returns and applications are re-
quired to be filed on or before July 1 of
each year thereafter during which tax-
able activity continues. Changes in own-
ership which require a return and appli-
cation 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 con-
tinue the business of a partnership.

(3) Gontinuance of the corporate busi-
ness by a stockholder after the corpora-
tion is dissolved.

(b) Supplemental Applications for
Registry.—Change of place of business
or residence address must be registered
by filing a Form 11-C, checking the block
designated ‘Supplemental Return and
Application,” and stating 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, which-
ever occurs first.

Any other change must also be reg-
istered within 30 days after such change.
Examples of such 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 execu-
tor or administrator, or other legal repre-
sentative, (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) With-
drawal 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 ad-
ditional 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 own account shall register the
name, address, and number appearing on
the special tax stamp of each such agent
or employee by filing a Form 11-C desig-
nated “Supplemental Return.” Likewise,
an agent or employee receiving wagers
on behalf of another shall register the
name and address of each additional per-
son by whom he is engaged to receive
wagers within 10 days after he is so
engaged.

3. Where to File:
If your principal business,

office or agency, or legal
| the case of an
di

Use this address

Vv

New Jersey, New York City Internal Revenue Service
and counties of Nassau,
Rockland, Suffolk, and
Westchester

New York (all other
counties), Connecticut,
Maine, Massachusetts,

New Hampshire, Rhode
Island, Vermont

District of Columbia,
Delaware, Maryland,
Pennsylvania

enter
1040 Waverly Avenue
Holtsville, N.Y. 11799

Internal Revenue Service

Center
310 Lowell Street
Andover, Massachusetts
01812

Internal Revenue Service

11601, Roosevelt Boulevard
Philadelphia, Pennsylvania
155

Alabama, Florida, Internal Revenue Service
Georgia, Mississippi, enter
South Carolina 4300 Buford Highway

Chamblee, Georgia 30006

Michigan, Ohio Internal Revenue Service
enter
Cincinnati, Ohio 45298

Internal Revenue Service

Arkansas, Kansas,
Loursiana, New Mexico,

enter
Oklahoma, Texas 3651 S. Interregional

Highway
Austin, Texas 78740
Alaska, Arizona, Colorado, Internal Revenue Service

Idaho,’ Minnesota, Center
1160 West 1200 South Street

Montana, Nebraska,
Nevada, ‘North Dakota, Ogden, Utah 84201
Oregon, South Dakota,

Utah, Washington,

Wyoming
Illinois, lowa, Missouri, — Internal Revenue Service
Wisconsin Center

2306 E. Bannister Road
Kansas City, Missouri 64170

Internal Revenue Service

Califorma, Hawaii

Center
5045 East Butler Avenue
Fresno, California 93888

Hentuciy, North Internal Revenue Service

Indiana,

3131 Democrat Road

jay West Virginia
Vita Het re Memphis, Tennessee 38110

if you have no legal residence, principal
place of business or principal office or agency
in any Internal Revenue district, file your re-
turn with the Internal Revenue Service Center,
11601 Roosevelt Boulevard, Philadelphia, Penn-
sylvania 19155.

4. Computation of the Special Tax on
Wagering.—Special tax liability is com-
puted from the first of July of each year,
or the first day of the month during which
business is commenced, to the thirtieth
day of June following. For a renewal or
for a business begun during July, the tax
is $50.00. Where business is begun after
the month of July, the tax to be remitted
is computed by multiplying the monthly
rate of $4.1624 by the number of months
remaining in the fiscal year. If the result-
ing amount involves a fraction, the full
cent must be included. Example: If a per-
son first commences business in Novem-
ber, liability should be computed as fol-
lows: $4.16%4 x 8 (the number of months
remaining in the fiscal year) equals
$33.31, or $33.34, the amount to be
remitted. Enter the amount of tax in the
block on the face of the return.

5. Penalties.—If the return is not filed
prior to engagement in the activity which
results in liability for the occupational tax
on wagering, the penalty prescribed by
sections 6651 and 6653 may be incurred.
In addition, under the provisions of sec-
tion 7262, any person who does any act
which makes him liable for the special
tax, without having paid such tax, shall
be fined not less than $1,000 and not
more than $5,000. For willful failure to
file a return or pay the tax, the penalties
under sections 7201 and 7203 may be
imposed.

Under the general provisions of sec-
tion 1001 of Title 18 of the United States
Code, 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.

“fe US, GOVERNMENT PRINTING OFFICE : 1578—O-530-717 48-0627165