Type or print. 

Number, street, and room or suite no.

City, state, and ZIP code

Check one: First return Renewal return

For IRS Use 

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 $ 

FF 

Alias, style, or trade name, if any FP 

I 

Occupational Tax T $ 

1 Enter the date (month and day) you will start accepting wagers during the tax period

2 Tax (see instructions) $

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

Additional Information (for principal only)

4 If the taxpayer is a firm, partnership, or corporation, give the true name of each member or officer.

True name Title Home address Social security n

5 Are you or will you be engaged in the business of accepting wagers on your own account? Y

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 identif

6 If you receive or will be receiving wagers on behalf of or as an agent for some other person or persons, give th

address, and employer identification number of each person.

True name Address Employer identif

Under penalties of perjury, I declare that I have examined this return and/or registration (including any accompanying statements 

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 

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)

Sign

Here Signature Date Title 

Daytime telephone number

( )
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

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.

1. You change your business 

address. You must register the c

accepting wagers at the new ad

the end of the 30-day period aft

of address, whichever occurs fir

2. You continue for the remain

period, as the surviving spouse o

executor, administrator, or other 

representative, the business of a 

person who paid the occupation

to pay the occupational tax on wagering. You

must pay the occupational tax if you accept

taxable wagers for yourself or another person.

There are two amounts of occupational tax

($50 or $500). One or the other applies

depending on whether the wagers you accept

are authorized by the laws of the state in

which you accept the wager. See the

instructions for Line 2 to determine your

occupational tax. Your cancelled check is

proof of registration and payment.

Where to file. Mail Form 11-C, your check or

money order, and Form 11-C(V) to:

3. You continue for the remain

period the business as a receive

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 remain

period the business as an assign

creditors.

5. One or more members with

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 chan

7. You engage a new agent to 

wagers. You must file a supplem

registration to report the name, a

EIN of each new agent within 10 

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. You must complete li

have previously filed Form 11-C 

engaged to receive wagers for a

must register the name, address

each new person who engaged 

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. This is the person who

makes a profit or risks loss depending on the

outcome of the event or contest for which the

wager is accepted.

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 (for example, 2006 or 2007).

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

Line 3. You must check one of t

See Who must file for the definit

principal and agent. Principals a

the excise tax on wagers, which 

and filed monthly on Form 730, 

Return for Wagers.

Lines 4 and 5. These lines are t

completed by principals only. En

information for officers and/or pa

company on line 4. Enter on line 

and address of each location wh

will be conducted. Enter the num

agents who accept wagers for y

and their names, addresses, and 

line 5c.

Line 6. This line is to be comple

accepting wagers on behalf of a

the name, address, and EIN of e

or company on whose behalf yo

wagers.

$500

tax

$50

tax

Supplemental Regist

Address. If you are an individual, enter your

home address.

Note. This tax is paid once for each period

that begins July 1. If you are required to file a

supplemental registration, do not pay the tax

a second time.

Line 7. A supplemental registrat

filed by principals within 30 days 

items 1 and 7 below) when any 

following events occur.

How to file a supplemental reg

Complete the name, address, EI

address, and alias lines. Also, be 

check the “supplemental registra

Then check the applicable box o

enter the information that has ch

line 7, including the date of the 

change. Do not complete lines 1

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.

an EIN by calling 1-800-829-4933, or you can

fax or mail Form SS-4, Application for

Employer Identification Number, to the IRS.

Payment voucher. Complete Fo

Payment Voucher, and file it with 

and your payment.

Definitions. See the Instructions for Form 730

for the definition of sports event, contest,

wagering pool, and lottery.

Refund. A refund for an overpayment of the

occupational tax may be claimed on Form

8849, Claim for Refund of Excise Taxes,

using Schedule 6. See the Instructions for

Form 8849 for details.

Line 2. Use the table below to determine the

tax. The $50 tax applies if all wagers

(including those accepted by an agent for

another) are authorized under the laws of the

state in which accepted. If you intend to

accept wagers that are not authorized by the

state, the $500 tax applies. The tax is payable

for the period that begins July 1 of each year.

If you start accepting wagers after July 31,

the tax is prorated for the first year.
Complete Form 11-C(V), Payment Voucher, and file it

with Form 11-C, Occupational Tax and Registration

Return for Wagering. We will use Form 11-C(V) to

credit your payment more promptly and accurately,

and to improve our service to you.

Specific Instructions

Box 1. If you do not have an EIN, apply for one online.

Go to the IRS website at www.irs.gov/businesses and

click on the “Employer ID Numbers” link under

“Businesses Topics.” You may also apply for an EIN

by calling 1-800-829-4933, or you can fax or mail Form

SS-4, Application for Employer Identification Number,

to the IRS.

● Enclose your check or money order made 

the “United States Treasury.” Be sure to ente

EIN, “Form 11-C,” and the tax period on you

money order. Do not send cash. Do not stap

Form 11-C(V) or your payment to Form 11-C 

each other).

● Detach Form 11-C(V) and send it with your 

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

If you have your return prepared by a third party,

provide Form 11-C(V) to the return preparer.

Box 3. Enter the same year and month you 

the “Return for period from” line at the top o

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

that begins July 1, 2006, enter 200607.

Box 4. Enter your name and address as sho

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

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 

Y Y YMM

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

Internal Revenue Service

Cincinnati, OH 45999-0101

(Rev. April 2006)
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

Copying, assembling, and send

to the IRS, 16 min.

If you have comments concern

accuracy of these time estimates 

suggestions for making this form 

would be happy to hear from yo

write to the Internal Revenue Se

Products Coordinating Committe

SE:W:CAR:MP:T:T:SP, 1111 Con

Ave., NW, IR-6406, Washington, 

Do not send the form to this add

Instead, see Where to file on pa

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.