Form 5754

OMB No. 1545-0239

Statement by Person(s) Receiving Gambling Winnings

(Rev. July 2000)

 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 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. 7-2000)

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.

Return to payer. Do not

send to the IRS.
Form 5754 (Rev. 7-2000) 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.

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

figure and collect the right amount of tax. Regulations

section 31.3402(q) requires you to furnish an information

return to the payer if you receive gambling winnings

either for someone else or as a member of a group of

winners on the same winning ticket. Section 6109 and its

regulations require you to show your taxpayer

identification number to persons who must file

information returns with the IRS to report certain

information. Routine uses of this information include

giving it to the Department of Justice for civil and criminal

litigation, and to cities, states, and the District of

Columbia for use in administering their tax laws. If you fail

to provide this information in a timely manner, you may

be subject to penalties.

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.

Form 5754 (Rev. 7-2000)