Form 11-C Occupational Tax and Registration Return for Wagering OMB No. 1545-0236

(Rev. September 1992) Expires 6-30-95

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 such person:

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 such 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. Form 11-C (Rev. 9-92)

Cat. No. 16166V

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. 9-92) 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

Copying, assembling, ownership.

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 more

simple, we would be happy to hear from you.

You can write to both the Internal Revenue

Service, Washington, DC 20224, Attention:

IRS Reports Clearance Officer, T:FP; and the

Office of Management and Budget,

Paperwork Reduction Project (1545-0236),

Washington, DC 20503. DO NOT send the

tax form to either of these offices. Instead,

see Where To File below.

Employer Identification Number.—If you are

required to file Form 11-C but do not have an

EIN, 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 EIN.

1. You change your business or home

address.

General Instructions

(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

person who paid the occupational tax.

Purpose of Form.—Form 11-C is used to

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

Internal Revenue Service Center, Ogden, UT

84201.

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.

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 and 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 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 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.

This line is used when principal operators

or employee-agents must file a supplemental

registration return. A supplemental registration

return must be filed within 30 days after any

of the following occur.

Principal Operators

Note: Do not complete lines 1, 2, 4, 5, or 6 if

this is a supplemental return. Complete the

name, address, EIN, business address, and

alias lines. Check the “Supplemental

registration return” box, the applicable box on

line 3, and enter the information that has

changed on line 7.

Signature.—This return must be signed and

dated.

Employee-Agents

$500

rate

$50

rate

Supplemental Registration

Return (Line 7)

Changes To Note

1. All filers of this form are required to have

an employer identification number (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.

2. All filers of this form must check the

applicable box on line 3 to indicate if you are

a principal operator or an employee-agent.

3. Part II has been revised and should be

completed by principal operators only. Part III

has been revised and should be completed

by employee-agents only.

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.