Form 5754

Statement by Person(s) Receiving Gambling Winnings

(Rev. August 2005)

 Payers of gambling winnings should see the separate Instructions for Forms W-2G

and 5754.

Department of the Treasury

Internal Revenue Service

Date won Type of winnings Game number Machine number 

Person to Whom Winnings Are Paid

Name Address

Taxpayer identification number Other I.D. Amount received

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

(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 

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

Signature  Date 

Cat. No. 12100R 

Part I

Part II

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

For Privacy Act and Paperwork Reduction Act Notice, see back of form.
Form 5754 (Rev. 8-2005) 

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

(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.

figure and collect the right amount of ta

section 31.3402(q) requires you to furn

return to the payer if you receive gamb

either for someone else or as a membe

winners on the same winning ticket. Se

regulations require you to show your ta

identification number to persons who m

information returns with the IRS to repo

information. Routine uses of this inform

giving it to the Department of Justice fo

litigation, and to cities, states, and the 

Columbia for use in administering their 

also disclose this information to other c

tax treaty, to federal and state agencie

nontax criminal laws, or to federal law 

intelligence agencies to combat terroris

provide this information in a timely man

subject to penalties.

The time needed to complete this fo

depending on individual circumstances

average time is 12 minutes.

If you have comments concerning th

time estimate or suggestions for makin

simpler, we would be happy to hear fro

write to the Internal Revenue Service, T

Coordinating Committee, SE:W:CAR:M

Constitution Avenue, NW, IR-6406, Wa

20224. Do not send this form to this ad

return it to the payer.

Part II

Instructions for Recipient of Gambling

Winnings

You are not required to provide the i

requested on a form that is subject to t

Reduction Act unless the form displays 

control number. Books or records relat

instructions must be retained as long a

may become material in the administra

Revenue law. Generally, tax returns and 

information are confidential, as required 

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. 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