Form 11-C Occupational Tax and Registration Return for Wagering

(Rev. January 2001) OMB No. 1545-0236

Department of the Treasury Return for period from , to June 30, Internal Revenue Service (Month and day)

Name

Use IRS label.

Otherwise,

type or print. 

Number, street, and room or suite no.

Employer identification number

City, state, and ZIP code

Check one: First return Renewal return

For IRS Use Only

Supplemental registration (Do not complete lines 1, 2, 4, 5, and 6.)

Business address (if different from your home address or address entered above)

T $ 1

FF 2

Alias, style, or trade name, if any FP 3

I 4

Occupational Tax T $ 5

1 Enter the date (month and day) you will start accepting wagers during the tax period

2 Tax (See instructions.) $

Make your check or money order payable to the "United States Treasury" for the tax due and send with the return.

Additional Information (for principal only)

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

True name Title Home address Social security number

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.

a Name and address where each business is or will be conducted:

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

b Number of agents engaged in receiving wagers on your behalf 

c True name, address, and employer identification number of each agent:

True name Address Employer identification number

6 If you receive or will be receiving wagers on behalf of or as agent for some other person or persons, give true name,

address, and employer identification number of each person.

True name Address Employer identification number

Under penalties of perjury, I declare that I have examined this return and/or registration (including any accompanying statements or lists), and, to

the best of my knowledge and belief, it is true, correct, and complete.

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 16166V Form 11-C (Rev. 1-2001)

Part IV

Part III

Part I

Part II

3 Check one:

Additional Information (for agents accepting wagers on behalf of others)

Supplemental Registration (See instructions.)

7 Explain why you are filing a supplemental registration. Include the date of the event.

Principal Agent accepting wagers for another (See instructions.)

(Year) (Year)

Daytime telephone number

Sign

Here  Signature Date Title 

( )
Form 11-C (Rev. 1-2001) Page 2

Privacy Act and Paperwork Reduction Act

Notice. We ask for the information on this form

to carry out the Internal Revenue laws of the

United States. We need it to figure and collect

the right amount of tax. Subtitle D,

Miscellaneous Excise Taxes, Chapter 35, Section

4411 imposes a special tax on each person who

is engaged in receiving wagers for or on behalf

of any person liable for the tax on wagers.

Section 4412 requires that person to register

with the IRS. This form is used to determine the

amount of the tax that you owe and to register

certain information with the IRS. Section 6011

requires you to provide the requested

information if this tax is applicable to you.

Section 6109 requires you to provide your

taxpayer identification number. Routine uses of

this information include giving it to the

Department of Justice for civil and criminal

litigation, and to cities, states, and the District of

Columbia for use in administering their tax laws.

If you fail to provide this information in a timely

manner, you may be subject to penalties and

interest.

The time needed to complete and file this

form will vary depending on individual

circumstances. The estimated average time is:

Recordkeeping, 7 hr. 24 min.; Learning about

the law or the form, 57 min.; Preparing the

form, 2 hr., 3 min.; and Copying, assembling,

and sending the form to the IRS, 16 min.

When to file. File the first return before wagers

are accepted. After that, file a renewal return by

July 1 for each year wagers are accepted. A first

return is also due in certain situations in which

there has been a change in ownership or control.

The return must be filed within 30 days after new

members are admitted to a firm or partnership; a

corporation is formed to continue the business

of a partnership; or a stockholder continues the

business of a dissolved corporation.

If you have comments concerning the

accuracy of these time estimates or suggestions

for making this form simpler, we would be happy

to hear from you. You can write to the Tax

Forms Committee, Western Area Distribution

Center, Rancho Cordova, CA 95743-0001. Do

not send the form to this address. Instead, see

Where to file above.

1. You change your business or home address.

General Instructions

Section references are to the Internal Revenue

Code unless otherwise noted.

2. You continue for the remainder of the

period, as the surviving spouse or child,

Purpose of form. Form 11-C is used to register

certain information with the IRS and to pay the

occupational tax on wagering.

Where to file. Mail the return to

3. You continue for the remainder of the

period the business as a receiver or trustee in

bankruptcy.

Mail the return using the U.S. Postal Service

or other designated private delivery service. See

the instructions for your income tax return for

more information. 4. You continue for the remainder of the

period the business as an assignee for creditors.

5. One or more members withdraws from a

firm or partnership.

Penalties. There are penalties for not filing on

time, for accepting wagers before paying the tax,

and for willfully failing to file the return. There are

also penalties for making or helping to make

false returns, documents, or statements.

6. The corporate name is changed.

7. You engage a new agent to receive wagers.

You must file a supplemental registration to

report the name, address, and EIN of each new

agent within 10 days after you engage the agent.

Confidentiality of information. No Treasury

Department employee may disclose information

you supply in relation to wagering tax except

when needed to administer or enforce the tax

law. See section 4424 for more information. Agents must complete line 7 if you have

previously filed Form 11-C and are engaged to

receive wagers for another. You must register

the name, address, and EIN of each new person

who engaged you within 10 days after being

engaged.

Who must file. File Form 11-C if you are a

principal or an agent.

1. A principal is a person who is in the

business of accepting taxable wagers for his or

her own account.

2. An agent is a person who accepts taxable

wagers on the principal’s behalf.

Specific Instructions

Return period. Enter the month, day, and year

that begins the return period. Also, enter the

ending year. Write the year as a 4-digit number,

i.e., 2000, 2001, etc.

Line 2. There are two amounts of tax, $500 and

$50, payable for the year that begins July 1. The

$50 tax applies only if all wagers (including those

accepted by an agent for another) are authorized

under the laws of the state in which accepted. If

you start accepting wagers after July 31, the tax

is prorated for the first year. Use the table below

to determine the tax.

If you start

accepting

wagers in

July $500.00 $50.00

August 458.33 45.83

September 416.66 41.66

October 375.00 37.50

November 333.33 33.33

December 291.66 29.16

January 250.00 25.00

February 208.33 20.83

March 166.66 16.66

April 125.00 12.50

May 83.33 8.33

June 41.66 4.16

Line 3. You must check one of the boxes. See

Who must file for the definition of principal and

agent. Principals are liable for the excise tax on

wagers, which is reported and filed monthly on

Form 730, Tax on Wagering.

Lines 4 and 5. These lines are to be completed

by principals only. Enter applicable information

for officers and/or partners of the company on

line 4. Enter on line 5a the name and address of

each location where business will be conducted.

Enter the number of agents who accept wagers

for you on line 5b and their names, addresses,

and EINs on line 5c.

Line 6. This line is to be completed by agents

accepting wagers on behalf of another. Enter the

name, address, and EIN of each person or

company on whose behalf you accept wagers.

$500

tax

$50

tax

Supplemental Registration

Address. If you are an individual, enter your

home address.

Note: This tax is paid once for each taxable

period. If you are required to file a supplemental

registration, do not pay the tax a second time.

Line 7. A supplemental registration must be filed

by principals within 30 days (except see Agents

below) when any of the following events occur.

How to file a supplemental registration.

Complete the name, address, EIN, business

address, and alias lines. Also, be sure to check

the “supplemental registration” box. Then check

the applicable box on line 3 and enter the

information that has changed on line 7, including

the date of the event of change. Do not

complete lines 1, 2, 4, 5, or 6 for a supplemental

registration.

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.

Signature. Form 11-C must be signed by a

person who has authority to sign for the

taxpayer.

Internal Revenue Service Center

Cincinnati, OH 45999-0101

Line 1. Enter the day and month that you will

start accepting wagers. A full month’s tax is due

regardless of which day you start accepting

wagers during a month.

Taxable wagers include those placed:

● On a sports event or contest with a person

engaged in the business of accepting wagers on

a sports event or contest.

● In a wagering pool on a sports event or

contest if the pool is conducted for profit.

● In a lottery conducted for profit (other than a

state-conducted lottery). The term lottery

includes the numbers game, policy, punch

boards, and similar types of wagering.

What is not taxed. The tax is not imposed on

the following five items:

● A parimutuel wagering enterprise, including

horse racing, dog racing, and jai alai, when

licensed under the laws of the state in which

accepted.

● Coin-operated devices, such as pinball

machines.

● Sweepstakes, wagering pools, or lotteries that

are conducted by an agency of a state, if the

wager is placed with the state agency or its

authorized agents or employees.

● Games of the type in which usually all persons

placing wagers in the game are present when

wagers are placed, winners are determined, and

prizes or other property are distributed.

● Drawings conducted by an organization

exempt from tax under sections 501 or 521, as

long as the net proceeds of the drawing do not

inure to the benefit of a private shareholder or

individual.

Employer Identification Number (EIN). Enter

your EIN. If you do not have an EIN, use Form

SS-4, Application for Employer Identification

Number, to apply for one. You can get this form

at Social Security Administration offices or by

calling 1-800-TAX-FORM (1-800-829-3676). You

can ask for an EIN by calling the Tele-TIN phone

number for your service center listed in the

instructions for Form SS-4.

Caution: The IRS will no longer issue a letter as

proof of registration and payment. Your canceled

check is proof of registration and payment.

executor, administrator, or other legal

representative, the business of a deceased

person who paid the occupational tax.