Special Tax Return and Application

Form 11-€ For Registry—Wagering OMB No, 1545-0236

(Rev. November 1981)

Department of the Treasury Return for period from = = = ,19_ to June 30, 19...
Internal Revenue Service (Month, day, and year)
Check one: |] First return and application |] Renewal return and application |] Supplemental return and application
| True name Social security number
A
=| Alias, style, or trade name, if any Employer identification no. (see instruction 1)
a
g| Number and street For Internal Revenue Use Only
2
5
|| City, County, State and ZIP code punter
3/2 Date a
s issued &
2 g| Number and street TS. eee
“Ne FRO. 2
| City, County, State and ZIP code FP
a
1
3 If this is a supplemental application, please explain and give your Special Tax Stamp TS
Number and employer identification number. (See instruction 2(b).) > Compute tax as explained
. - . in instruction 4, and enter
amount due here . . > | $
Make check or money order payable to the
Internal Revenue Service for the amount
of tax due and remit with return.

If additional space is required for items 4, 5(a), 5(c), or 6, attach additional sheets, identifying each entry as to item number.

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? - [J Yes [] No

If “Yes,’’ complete (a), (b), and (c) of this item.
(a) Name and address where each such business is or will be conducted.
Name of location Address (Number and street) City, State, and ZIP code

(b) Number of employees and/or agents engaged in receiving wagers on your behalf P..
(6) True name, special stamp number, address, and social security number of each such person.
True name Special stamp no, Address

6 Do you receive or will you be receiving wagers on behalf of or as agent for some other person or persons? . . [] Yes [7] No

If “Yes,” give true name, address, and social security number of each such person.
True name Address Social security number

Signature and Verification

| declare under the penalties of perjury that this return and/or application (including any accompanying statements or lists) has been examined
by me and to the best of my knowledge and belief is true, correct, and complete.

Signature > Title (Owner, ete.) > Date >

For Paperwork Reduction Act Notice, see back of form. Form 11—-C (rev. 11-81)



Instructions
(References are to the Internal Revenue Code.)

Paperwork Reduction Act Notice.—
The Paperwork Reduction Act of 1980
says we must tell you why we are collect-
ing this information, how we will use it,
and whether you have to give it to us. We
ask for the information to carry out the
Internal Revenue laws of the United
States. 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. You are required to give us this
information.

1. Who Must File.—Every person who
is liable for the 2-percent excise tax im-
posed by section 4401, and every per-
son who is engaged in receiving wagers
for or on behalf of any person so liable,
is subject to a special tax of $500 per year
imposed by section 4411, and must file
Form 11-C.

In addition, you must file Form 730
each month to pay and report the tax on
wagers.

Section 4421 defines the term ‘‘wager”’
to mean (1) any wager with respect to
a sports event or a contest placed with
a person engaged in the business of ac-
cepting such wagers, (2) any wager
placed in a wagering pool with respect
to a sports event or a contest, if such
pool is conducted for profit, and (3) any
wager placed in a lottery conducted for
profit.

The term “‘lottery” includes the num-
bers game, policy, and similar types of
wagering. The term does not include: (A)
any game of a type in which usually (1)
the wagers are placed, (2) the winners
are determined, and (3) the distribution
of prizes or other property is made, in the
presence of all persons placing wagers in
such game; and (B) any drawing con-
ducted by an organization exempt from
tax under sections 501 and 521, if no
part of the net proceeds derived from
such drawing inures to the benefit of any
private shareholder or individual.

If you are required to file Form 11-C
and have not applied for an employer
identification number, please complete
Form SS-4, Application for Employer
Identification Number, and attach it to
your return when you file. If you have ap-
plied for a number but have not received
notice of it by the time you must file,
please write ‘Number applied for’ in the
block on the form for the number.

2, When To File.—(a) First and Re-
newal Returns and Applications for Reg-
istry—Form 11-C serves two purposes:
(A) A special tax return and (B) an appli-
cation for registry. The first return and
application for registry must be filed prior
to engaging in the activity which results
in liability for the special tax on wagering.
Renewal returns and applications are re-
quired to be filed on or before July 1 of
each year thereafter during which tax-
able activity continues. Changes in own-
ership which require a return and appli-
cation for registry, and which result in
special tax liability, include the following:

(2) Admission of new members to a firm or
partnership.

(2) Formation of a corporation to continue
the business of a partnership.

(3) Continuance of the corporate business by
a stockholder after the corporation is dissolved.

(b) Supplemental Applications for
Registry.—Change of place of business
or residence address must be registered
by filing a Form 11-C, checking the block
designated “Supplemental Return and
Application,” and stating the new ad-
dress and the date of change before: (1)
you engage in any wagering activity at
the new address, or (2) the termination
of a 30-day period which begins on the
day after the date of such change, which-
ever occurs first.

Any other change must also be reg:
istered within 30 days after such change.
Examples of such other changes include
the following: (1) Continuance of the
operation of a business of a deceased
person, who has paid the special tax,
by the surviving spouse or child, or execu-
tor or administrator, or other legal repre-
sentative, (2) Continuance of a business
by a receiver or trustee in bankruptcy, (3)
Continuance of a business by an assignee
for the benefit of creditors, (4) With-
drawal! from a firm or partnership of one
or more members, and (5) Mere change
of corporate name. Failure to comply
with these requirements will result in ad-
ditional tax and penalty. The taxpayer's
special tax stamp must accompany such
supplemental application for proper
notation.

Not later than 10 days after engaging
a new agent or employee to receive
wagers, an individual accepting wagers
on his or her own account shall register
the name, number appearing on the
special tax stamp, address, and social
security number of each such agent or
employee by filing a Form 11-C desig-
nated “Supplemental Return.” Likewise,
an agent or employee receiving wagers
on behalf of another shall register the
name, address, and social security num-
ber of each additional person by whom
he or she is engaged to receive wagers
within 10 days after being so engaged.

3(a). Where to File:

Mf your principal business,
office or agency, or legal
ce in the case of an

in Use this address

New Jersey, New York City
and counties of Nassau,
Rockland, Suffolk, and
Westchester

New York (ail other
counties), Connecticut,
Maine, Massachusetts,
New Hampshire, Rhode
Island, Vermont
District of Columbia,
Delaware, Maryland,
Pennsylvania

Internal Revenue Service
enter
Holtsville, NY 00501

Internal Revenue Service
enter
Andover, MA 05501

Internal Revenue Service
enter
Philadelphia, PA_ 19255

Rlabama, Florida, Internal Revenue Service
Georgia,’ Mississippi,
South Carolina

Michigan, Ohio

enter
Atlanta, GA 31101
Internal Revenue Service

Center
Cincinnati, OH 45999

Internal Revenue Service
Center

Austin, TX_73301

Internal Revenue Service

Arkansas, Kansas,
Louisiana, New Mexico,
Oklahoma, Texas

‘Alaska, Arizona, Colorado,
Idaho,’ Minnesota, Montana, Center
Nebraska, Nevada, North Ogden, UT 84201
Dakota, Oregon, South

Dakota, Utah, Washington,
Wyoming

{ilinois, Towa,

Missouri, Wisconsin

Internal Revenue Service

‘enter
Kansas City. MO_64999
Internal Revenue Service

Center
Fresno, CA 93888

California, Hawaii

Internal Revenue Service

indiana, Kentucky,
Center
Memphis, TN _ 37501

North Carolina, Tennessee,
Virginia, West Virginia

If you have no legal residence, principal place of
business or principal office or agency in any Internal
Revenue district, file your return with the Internal Rev-
enue Service Center, Philadelphia, Pennsylvania 19255.

(b) Hand-carried _ returns.—Returns
which are filed by hand-carrying (as de-
fined in |.R.C. regulations section
301.6091-1(c)) shall be filed with the
District Director or with any permanent
post of duty within that Internal Revenue
district.

4. Computation of the Special Tax on
Wagering.—Special tax liability is com-
puted from the first of July of each year,
or the first day of the month during which
business is commenced, to the thirtieth
day of June following. For a renewal or
for a business begun during July, the tax
is $500.00. Where business is begun after
the month of July, the tax to be remitted
is computed by multiplying the monthly
rate of $41.66% by the number of months
remaining in the fiscal year. Example: If a
person first commences business in No-
vember, liability should be computed as
follows: $41.66%4x8 (the number of
months remaining in the fiscal year)
equals $333.33, the amount to be re-
mitted. Enter the amount of tax in the
block on the face of the return.

5. Penalties.—If the returt
prior to engagement in the acti
results in liability for the occupational tax
on wagering, the penalty prescribed by
sections 6651 and 6653 may be incurred.
In addition, under the provisions of sec-
tion 7262, any person who does any act
which makes that person liable for the
special tax, without having paid such tax,
shall be fined not less than $1,000 and
not more than $5,000. For willful failure
to file a return or pay the tax, the penal-
ties under sections 7201 and 7203 may
be imposed. For making and subscribing a
false return, statement or other document
under the penalties of perjury, or aiding,
or advising the preparation of such re-
turns, statements or other documents,
the penalties under sections 7206(1) and
7206(2) may be imposed.

Under section 1001 of Title 18,
U.S.C., whoever knowingly makes any
false or fictitious statement with respect
to the payment of the special tax, such
as the giving of a false name or address,
shall be fined not more than $10,000 or
imprisoned not more than 5 years, or

oth.

6. Disclosure of Wagering Tax Informa-
tion.—No Treasury Department official or
employee may disclose, except in connec-
tion with the administration or enforce-
ment of Internal Revenue taxes, any docu-
ment or record supplied by a taxpayer
in connection with such taxes, or any
information obtained through any such
documents or records. Additionally, cer-
tain documents related to the wagering
taxes, and information obtained through
such documents, may not be used against
the taxpayer in any criminal proceeding,
except in connection with the the admin-
istration or enforcement of Internal Rev-
enue taxes, See section 4424 for more
detailed information.