Form 11-C Occupational Tax and Registration Return for Wagering

(Rev. October 2003) OMB No. 1545-0236

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

Name

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) $

See Form 11-C, Payment Voucher, for how to make your payments.

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 an 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 4. Cat. No. 16166V Form 11-C (Rev. 10-2003)

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)

Sign

Here  Signature Date Title 

Daytime telephone number

( )
Form 11-C (Rev. 10-2003) Page 2

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

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,

executor, administrator, or other legal

representative, the business of a deceased

person who paid the occupational tax.

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 Form 11-C, your check or

money order, and the payment voucher 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., 2003, 2004, 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, Monthly Tax

Return for Wagers.

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.

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

What’s New?

Payment voucher. Complete Form 11-C(V),

Payment Voucher, and file it with Form 11-C

and your payment.

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.

New Form 11-C(V), Payment Voucher, must

be included with your return and payment. If

you usually receive Form 11-C from the IRS,

there should be a preaddressed Form 11-C

and a voucher page with a preaddressed

voucher. If you order Form 11-C from the IRS

or download it from the IRS website, a

voucher is included with Form 11-C.

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

can also complete the SS-4 online application

at www.irs.gov.
Form 11-C

Payment Voucher

Purpose of Form

Complete Form 11-C(V) and file it with Form 11-C,

Occupational Tax and Registration Return for

Wagering. We will use the completed voucher to credit

your payment more promptly and accurately, and to

improve our service to you.

Specific Instructions

Box 1—Employer identification number (EIN). If you

do not have an EIN, apply for one on Form SS-4,

Application for Employer Identification Number, and

write “Applied For” and the date you applied in this

entry space.

● Enclose your check or money order made payable to

the “United States Treasury.” Be sure to enter your

EIN, “Form 11-C,” and the tax period on your check or

money order. Do not send cash. Do not staple this

voucher or your payment to Form 11-C (or to each

other).

● Detach the completed voucher and send it with your

payment and Form 11-C. See Where to file on page 2.

If you have your return prepared by a third party,

provide this payment voucher to the return preparer.

Box 3. Enter the same year and month you entered on

the “Return for period from” line at the top of Form

11-C. For example, if your return is for the full period

that begins July 1, 2004, enter 200407.

Box 4—Name and address. Enter your name and

address as shown on Form 11-C.

Box 2—Amount paid. Enter the amount paid with

Form 11-C.

3 Enter year and month as shown on Form 11-C.

Y

Enter the amount of your payment. 

2

 Detach Here and Mail With Your Payment and Form 11-C. 

OMB No. 1545-0235

Form 11-C(V)

Department of the Treasury

Internal Revenue Service

Payment Voucher

Enter your employer identification

number.

4 Enter your business name (individual name if sole proprietor).

 Do not staple or attach this voucher to your payment or Form 11-C.

Enter your address.

Enter your city, state, and ZIP code.

1 Dollars Cents

Y Y YMM

Send Form 11-C, this voucher, and payment to:

Internal Revenue Service

Cincinnati, OH 45999-0101

(October 2003)
Form 11-C (Rev. 10-2003) Page 4

Privacy Act and Paperwork Reduction Act

Notice. We ask for the information on Form

11-C 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. 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. Form

11-C is used to determine the amount of the

tax that you owe and to register certain

information with the IRS. Section 6109

requires you to provide your employer

identification number. Routine uses of this

information include giving

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.

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 Products Coordinating

Committee, Western Area Distribution Center,

Rancho Cordova, CA 95743-0001. Do not

send the form to this address. Instead, see

Where to file on page 2.

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.

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.