Form 5754

OMB No. 1545-0239

Statement by Person(s) Receiving Gambling Winnings

(Rev. September 1997)

© Payers of gambling winnings should see the separate Instructions for Forms 1099,

1098, 5498, and W-2G.

Department of the Treasury

Internal Revenue Service

Date won Type of winnings Game number Machine number Race number

Person to Whom Winnings Are Paid

Name Address

Federal income tax

withheld

Taxpayer identification number Other I.D. Amount received

Persons to Whom Winnings Are Taxable (continued on page 2)

(e) Winnings from

identical wagers

(b) Taxpayer

identification number (a) Name (c) Address (d) Amount won

Under penalties of perjury, I declare that, to the best of my knowledge and belief, the names, addresses, and taxpayer identification numbers that I have furnished correctly

identify me as the recipient of this payment and correctly identify each person entitled to any part of this payment and any payments from identical wagers.

Signature © Date ©

Cat. No. 12100R Form 5754 (Rev. 9-97)

Part I

Part II

© Recipients of gambling winnings should see the instructions on the back of this form.

For Paperwork Reduction Act Notice, see back of form.

Return to payer. Do not

send to the IRS.
Form 5754 (Rev. 9-97) Page 2

Persons to Whom Winnings Are Taxable (continued from page 1)

(e) Winnings from

identical wagers

(b) Taxpayer

identification number (a) Name (c) Address (d) Amount won

Purpose of form. You must complete Form 5754 if you receive gambling winnings

either for someone else or as a member of a group of winners on the same

winning ticket. The information you provide on the form enables the payer of the

winnings to prepare Form W-2G, Certain Gambling Winnings, for each winner to

show the winnings taxable to each.

Complete Part II to identify each winner and each winner’s share of the

winnings. If you are also one of the winners, enter your information first in Part II

by entering “Same as above” in columns (a), (b), and (c) and the applicable

amounts in columns (d) and (e). Then complete columns (a) through (e) for each of

the other winners. Return the form to the payer.

Taxpayer identification number. The taxpayer identification number for an

individual is the social security number or individual taxpayer identification

number. For all others, it is the employer identification number.

Completing the form. If you are the person to whom gambling winnings are paid,

enter your name, address, and taxpayer identification number in Part I. If the

winnings are from state-conducted lotteries, the box labeled “Other I.D.” may be

left blank. The total amount received and the total Federal income tax withheld

must be entered in the remaining columns.

Signature. If Federal income tax is withheld, the person who receives the

winnings must sign and date the form. If no Federal income tax is withheld, no

signature is required.

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.

The time needed to complete this form will vary depending on individual

circumstances. The estimated average time is 12 minutes.

If you have comments concerning the accuracy of this time estimate 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 this form to this address.

Instead, return it to the payer.

Part II

Instructions for Recipient of Gambling Winnings

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 Code section 6103.