Form 5754

OMB No. 1545-0239

Expires 1-31-95

Statement by Person(s) Receiving Gambling Winnings

(Rev. February 1992)

© 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. 2-92)

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.
Form 5754 (Rev. 2-92) 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

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; 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.” can 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 provide 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 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 (1545-0239),

Washington, DC 20503. DO NOT send this form to either of these offices.

Instead, return it to the payer.

Part II

Instructions for Recipient of Gambling Winnings the payer of the winnings to prepare Form W-2G, Certain Gambling

Winnings, for each winner to show the winnings taxable to each.