Form 11-C Occupational Tax and Registration Return for Wagering

(Rev. November 1996) OMB No. 1545-0236

Department of the Treasury Return for period from , 19 to June 30, 19 Internal Revenue Service (Month and day)

Name

Use IRS label.

Otherwise,

please print or

type.

Number, street, and room or suite no.

Employer identification number (See instructions.)

City, state, and ZIP code

Check one: First return Renewal return

For IRS Use Only

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

Business address

Date letter issued ©

T $ 1

FF 2

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

I 4

Occupational Tax T $ 5

1 Enter month you will start accepting wagers during the tax period

2 Tax (See instructions.) $

Make your check or money order payable to the Internal Revenue Service for the tax due and send with the return.

Additional Information (for principal operators 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 paid employee-agents engaged in receiving wagers on your behalf ©

c True name, address, and employer identification number of each employee-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

Signature

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.

Signature © Title (Owner, etc.) © Date ©

For Paperwork Reduction Act Notice, see back of form. Cat. No. 16166V Form 11-C (Rev. 11-96)

Part IV

Part III

Part I

Part II

3 Check one:

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

Supplemental Registration Return (See instructions.)

7 Explain why you are filing a supplemental registration return

Principal operator Employee-agent accepting wagers for another (See instructions.)
Form 11-C (Rev. 11-96) Page 2

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.

3. In a lottery run for profit, which includes the

numbers game, policy, punchboards, and similar

types of wagering. This category does not

include a game where the wagers are placed,

winners are picked, and prizes are given in front

of everyone who placed a wager. Nor does it

include a drawing run by a tax-exempt

organization if none of the profits go to a private

shareholder or individual.

The time needed to complete and file this

form will vary depending on individual

circumstances. The estimated average time is:

When To File.—File your first return before you

begin accepting wagers. After that, file a renewal

return by July 1 for each year you accept

wagers. You should also file another return when

certain changes in ownership occur and a

supplemental registration return when certain

other changes occur.

Recordkeeping 7 hr., 10 min.

Learning about the

law or the form 28 min.

Preparing the form 1 hr., 32 min.

Changes in ownership.—File another return

and pay the occupational tax within 30 days

after the day you admit new members to a firm

or partnership, you form a corporation to

continue the business of a partnership, or you

continue the business of a dissolved corporation

of which you were a stockholder. Check the

“First return” box on Form 11-C because this is

the first return for the new ownership.

Copying, assembling,

and sending the form

to the IRS 16 min.

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 below.

Employer Identification Number (EIN).—All

filers of this form are required to have an EIN.

Principal operators must report the EIN of

employee-agents on line 5c. Employee-agents

must report the EIN of a principal operator on

line 6.

1. You change your business or home

General Instructions address.

Section references are to the Internal Revenue

Code unless otherwise noted.

2. You continue, as the surviving spouse or

child, executor, administrator, or other legal

representative, the business of a deceased Purpose of Form.—Form 11-C is used to person who paid the occupational tax. register for wagering activity and to pay the

occupational tax on wagering. After you file Form

11-C and pay the tax, you will be issued a letter

as proof of registration and payment.

Where To File.—File your return with the

3. You continue the business as a receiver or

trustee in bankruptcy.

Hand-carried returns.—You may file your

return by hand carrying it to your district director

or to any local office within your Internal

Revenue district.

4. You continue the business as an assignee

for creditors.

5. One or more members withdraws from the

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. If you hire a new agent or employee to

receive wagers, you must file a supplemental

registration return to record the name, address,

and EIN of each new agent or employee. You

must file the return within 10 days after you hire

the employee or 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.

1. On sports events or contests with a person

in the business of accepting wagers.

2. In a wagering pool on a sports event or

contest if the pool is run for profit.

Employee-agents must complete line 7 if you

are hired to receive wagers for another. You

must register the name, address, and EIN of

each new person who hired you. You must file

the return within 10 days after being hired.

Who Must File.—You must file Form 11-C if you

are a principal operator or an employee-agent.

1. A principal operator is a person who is in

the business of accepting wagers for his or her

own account.

2. An employee-agent is a paid employee of a

principal operator who accepts wagers on the

principal operator’s behalf.

The term “wager” means wagers made:

Specific Instructions

Line 1.—Enter the 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.

Line 2.—There are two rates, $500 and $50 per

year. The $50 rate applies only if all wagers are

authorized under state law or if you are an

employee accepting wagers for another

authorized under state law. The tax year begins

on July 1. If you start accepting wagers after

July 31, the tax is prorated. Use the table in the

next column 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

operator and employee-agent. Principal

operators are liable for the excise tax on wagers,

which is reported on Form 730, Tax on

Wagering. Form 730 is filed monthly.

Lines 4 and 5.—These lines are to be completed

by principal operators only. Enter applicable

information for officers and/or partners of the

company on line 4. Enter the name and address

of each location where business will be

conducted on line 5a. You must enter the

number of paid employee-agents that work for

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

EINs on line 5c.

Line 6.—This line is to be completed by paid

employee-agents accepting wagers on behalf of

another. Enter the name, address, and EIN of

each person or company that you work for.

$500

rate

$50

rate

Supplemental Registration

Address.—If you are an individual, enter your

home address. Corporations, firms, associations,

partnerships, and all other entities must enter

their legal address.

Business Address.—If your business address is

different than your home address or legal

address, enter it in the business address block.

Note: This tax is paid once a year. If you are

required to file a supplemental return, do not pay

the tax a second time.

If you do not have an EIN, get Form SS-4,

Application for Employer Identification Number.

Form SS-4 has information on how to apply for

an EIN. Attach the completed SS-4 to your

return.

Line 7.—A supplemental registration must be

filed within 30 days (except as noted below) by

principal operators and employee-agents.

Principal operators must complete line 7

when any of the following events occur:

How to file a supplemental return.—Complete

the name, address, EIN, business address, and

alias lines. Also, be sure to check the

“supplemental registration return” box. Then

check the applicable box on line 3 and enter the

information that has changed on line 7. Do not

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

return.

You are not required to provide the

information requested on a form 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 Code section 6103.

A Change To Note

Beginning January 1, 1997, all Forms 11-C must

be filed (except hand-carried returns) with the

Internal Revenue Service Center, Cincinnati, OH.

See Where To File below.

Signature.—Be sure to sign and date the return.

Internal Revenue Service Center

Cincinnati, OH 45999-0101