com 11-€ Stamp Tax and Registration Return for Wagering

(Rev. November 1989)

OMB No. 1545-0236

Department of the Treasury Return for period from -, 19 ..... toJune 30, 19 ___.. Expires: 10-31-92
Internal Revenue Service
Name ‘Social security number
es pes abel.” Number and street
please print or Employer identification number
City, state, and ZIP code (See instructions.)

Check one: C1] First return CU Renewal return For IRS Use Only
C1 _ Supplemental registration return (Do not complete Part |.) 5

— stamp

Business address number
Date
issued >

T $e
FF

Alias, style, or trade name, if any

Stamp Tax (For first and renewal returns only)

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

2 Tax (See instructions.) . .
Make your check or money order payable tothe Internal Revenue Service for the tax due and remit with the return.

cag Supplemental Registration Return (See instructions.)

1 Enter tax stamp number
2 Enter reason for supplemental registration return 1 (See instructions. )

FREED Additional information (To be completed by all filers) (if more space is needed, attach additional sheets identifying each line number.)

1. If taxpayer isa firm, partnership, or corporation, give true name of members or officers
True name Title Home address Social security number

2. Are you or will you be engaged in the business of accepting wagers on your own account? . . .. . C1 Yes O1No
If “Yes,” complete (a), (b), and (c).
(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, stamp tax number, address, and social security number of each such person:
True name Stamp tax number Address Social security number

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

igs Signature

Under penalties of penury, | declare that | have examined this return and/or registration (including any accompanying statements or lists), and, to the best of my knowledge
and belief, itis true, correct, and complete.

Signature DP Title (Owner, etc.) Pe Date

For Paperwork Reduction Act Notice, see back of form. Form 11-C (Rev. 11-89)


Form 11-C (Rev. 11-89)

Page 2

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.

The time needed to complete and file this
form will vary depending on individual
circumstances. The estimated average time
is:

Recordkeeping . 7 hrs., 10 min.
Learning about the

law or the form . - 2hrs., 2 min.
Preparing the form 4hrs., 5 min.
Copying, assembling,

and sending the form

toIRS . 32 min

If you have comments concerning the
accuracy of these time estimates or
suggestions for making this form more
simple, we would be happy to hear from
you. You can write to the Internal Revenue
Service, Washington, DC 20224, Attention:
IRS Reports Clearance Officer, T:FP; or the
Office of Management and Budget,
Paperwork Reduction Project (as 0236),
Washington, DC 20503.

General Instructions
(Section references are to the Internal
Revenue Code, unless otherwise noted.)
Purpose of Form.—Form 11-C is used to
register to do business accepting wagers
and to pay the stamp tax on wagering. After
you file the form and pay the tax, you will be
issued a tax stamp as proof of registration
and payment. The tax is an annual tax that
applies in addition to the excise tax on
wagers. The excise tax on wagers is
reported on Form 730, Tax on Wagering.
Who Must File.—You must file Form 11-C
if you are in the business of accepting
wagers yourself or if you receive wagers for
someone else who is in the business. For
this purpose, the term “wager” includes
those made:

(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.

(3) Ina lottery run for profit. This includes
the numbers game, policy, punchboards,
and similar types of wagering. It does not
include a game where the wagers are
placed, winners are picked, and prizes are
given out in front of everyone who placed a
wager in the game. Also it does not include
a drawing run by a tax-exempt organization
if none of the profits go to a private
shareholder or individual
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.

Changes in ownership.—File another
return and pay the stamp 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.

Other changes. —Although you will not
owe more tax, you must file a supplemental
registration return within 30 days after any
of the following occurs:

(1) You change your business or home
address.

(2) You continue, as the surviving spouse
or child, executor, administrator, or other
legal representative, the business of a
deceased person who paid the stamp tax.

(3) You continue the business as a
receiver or trustee in bankruptcy

(4) You continue the business as an
assignee for creditors.

(5) One or more members withdraws
from the firm or partnership.

(6) The corporate name is changed.

Attach your tax stamp to the return for
proper notation when filing such
supplemental registration return.

If you hire a new agent or employee to
receive wagers, you must file a
supplemental registration return to record
the name, stamp tax number, address, and
social security number of each new agent or
employee. See Part Il, line 2(b) and (c) on
Form 11-C. Likewise, if you are hired to

receive wagers for another, you must
register the name, address, and social
security number of each new person by
whom you are hired. See Part Ill, line 3 on
Form 11-C. In either case, you must file the
return within 10 days after such hiring
occurs.

Figuring the Tax.—The tax is $500 per
year or $50 per year if all wagers are
authorized under the law of the state in
which accepted. The tax is figured from July
1 of each year, or from the first day of the
month in which you began business, to the
next June 30. If you began business during
July, the tax is $500. If you began business
after July, figure the tax by multiplying the
monthly rate of $41.66%4 by the number of
months left in the tax period.

Example.—lf you began business in
November, figure the tax as follows:
$41.66%4 x 8 (the number of months left in
the tax period) equals $333.33. Enter the
tax in Part |, line 2 on the return. If the
wagers are authorized under state law, the
tax is 10% of $333.33 = $33.33 because
the annual tax of $50 is 10% of $500.
Employer Identification Number.—If you
are required to file Form 11-C but do not
have an employer identification number,
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 yet
received it, write “applied for” in the block
on Form 11-C for the employer
identification number.

Where To File.—File your return with the
Internal Revenue Service Center, Ogden,
UT 84201

Hand-carried returns.—You may file your
return by hand carrying it to your district
director or to any post of duty within your
Internal Revenue district.
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.
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 taxes. See section
4424 for more information.

#U.S. Government Printing Office: 1989-261

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