J CORRECTED (it checked)

PAYER’S name, address, ZIP code, and Federal
identification number

1 Gross winnings

2 Federal income tax withheld

3 Type of wager

4 Date won

5 Transaction

OMB No. 1545-0238,

1990

Statement for
Recipients of

S Race Certain
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address, and ZIP code {9 Winner's taxpayer identification no. | 10 Window This information is
being furnished to
1 First |.D. 12 Second |.0. the Internal Revenue

Service,

113 State/Payer’s state identification no.

14 State income tax withheld

Under penalties of perjury, | declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identity
me as the recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part ofthese payments,

Signature >

Date >

Copy B

Report this income on
your Federal tax return. If
this form shows tax was
withheld, attach this copy
to your return.

Form W-2G

Department of the Treasury - Internal Revenue Service

[I CORRECTED (it checked)

PAYER’S name, address, ZIP code, and Federal
identification number

1 Gross winnings

] 2 Federal income tax withheld

OMB No. 1545-0238

1990

12 First 1.0.

212 Secondo.

1 3 Type of wager 4 Date won

Statement for
: | : Recipients of

| 5 Transaction 6 Race Certain
= Gambling

7Wi identical wager 7 inni
innngs from identical | ashver Winnings
WINNER'S name, address, and ZIP code ‘9 Winner's taxpayer identification no. J 10 Window This information Is

being furnished to
the Internal Revenue
Service

13 State/Payer’s state identification no

14 State income tax withheld

Under penalties of perjury, I declare that, to the best of my knowledge and belief. the name, address, and taxpayer identification number that | have furnished correctly identify

me as the recipient of this payment and any payments from identical wagers, and that no other person is entitied to any part of these payments

Signature >

Date >

Copy B

Report this income on
your Federal tax return. If
this form shows tax was
withheld, attach this copy
to your return.

Form W-2G

Department of the Treasury - Internal Revenue Service

J CORRECTED (it checked)

PAYER’S name, address, ZIP code, and Federal
identification number

1 Gross winnings

2 Federal income tax withheld

OMB No, 1545-0238

1990

11 First 1.0

[izseconaro

[3 Type of wager 4 Date won

Statement for
: Recipients of

57 ti 6 R A

ansaction ace Certain

aw 7 5 Gambling

innings from identical wagers [|_8 Cashier rae
Winnings

WINNER'S name, address, and ZIP code ‘9 Winner's taxpayer identification no. 10 Window

This information ts
being furnished to
the Internal Revenue
Service,

13 State/Payer's state identification no,

14 State income tax withheld

Signature >

Date >

Under penalties of perjury, | declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly entity
J} meas the recipient of this payment and any payments from identical wagers, and that no other person 1s entitled to any part of these payments,

i *

Copy B

Report this income on
your Federal tax return. If
this form shows tax was
withheld, attach this copy
to your return.

Form W-2G

Department of the Treasury - Internal Revenue Service




C1 CORRECTED (it checked)

PAYER’S name, addresS, ZIP code, and Federal
identification number

1 Gross winnings

2 Federal income tax withheld

OMB No. 1545-0238

1990

113 State, Payer’s state identification no.

14 State income tax withheld

3 Type of wager ‘4 Date won
: Statement for
i Recipients of
5 Transaction 6 Race Certain
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address, and ZIP code 19 winverstaipayer dentfcaton no. J 10 Window This © important tax
information and is being
furnished to the Internal
e. Ifyou ar
11 First 1.0. 12 Second |.D. Revenue Service, if you are

required to file a return, 2
negligence penalty or other

sanction may be imposed on
you if this income 1s taxable

and the IRS determines that
it has not been reported

Under penalties of peryury.| declare that to the best of my knowledge and belie, the name, addres, and taxpayer wéentification number that | have furnished correctly entity | Copy C
me as the recipient of this payment and any payments from identical wagers, and that no other person 1s entitled to any part of these payments. bs .
For Winner's
Signature > Date > Records
Form W-2G Department of the Treasury - Internal Revenue Service

_] coRRECTED (if checked)

PAYER’S name, address, ZIP code, and Federal
identification number

1 Gross winnings

2 Federal income tax withheld

OMB No. 1545-0238

1990

3 Type of wager 4 Date won
Statement for
‘ Recipients of
Tran i Ri i
5 Transaction 6 Race Certain
a Gambling
7 Winnings from identical wagers ashier 5 .
e 8 Winnings
WINNER'S name, address, and ZIP code 9 Winner's taxpayer identification no. 10 Window This is important tax
information and is being
furnished to the Internal
Md First .D 12 Second |.D. Revenue Service. If you are

13 State/Payer’s state identification no

14 State income tax withheld

required to file a return, a
negligence penalty or other

sanction may be imposed on
you if this income is taxable

and the IRS determines that
it has not been reported.

O CORRECTED (if checked)

PAYER'S name, address, ZIP code, and Federal
identification number

1 Gross winnings

2 Federal income tax withheld

Under penalties of penuty, | declare that, to the best of my Knowledge and belt, the name, address, and taxpayer identification number tat | have furnished covectiy dentty | Copy C
ime as the recipient ofthis payment and any payments from identical wagers, and that no other person is entitled to any part ofthese payments - 1
For Winner's
Signature > Date > Records
Form W-2G Department of the Treasury - Internal Revenue Service

OMB No. 1545-0238

1990

113 State/Payer's state identification no.

14 State income tax withheld

+3 Type of wager 4 Date won
: : Statement for
i i Recipients of
® "
5 Transaction 6 Race Certain
Gambling
7 Winnings from identical wagers 8 Cashier 7 .
rnings re = Winnings
WINNER'S name, address, and ZIP code 9 Winner's taxpayer identification no. 10 Window This 's important tax
information and \s being
furnished to the Internal
e ityou ar
11 First 1.0. 12 Second |.D. Revenue Service. if you are

required to file a return. a
negligence penalty or other

sanction may be imposed on
you if this income is taxable

and the IRS determines that
it has not been reported.

Signature >

Under penalties of perjury, declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identify
ime as the recipient of this payment and any payments trom identical wagers, and that no other person 1s entitled to any part of these payments.

Date >

Copy C
For Winner’s
Records

Form W-2G

Department of the Treasury - internal Revenue Service




J CORRECTED (it checked)

OMB No. 1545-0238

PAYER'S name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income tax withheld
identification number 1990
3 Type of wager “ Date won
: Statement for
‘ i Recipients of
5 Transaction 6 Race Certain
Gambling
7 Winnings from identical wagers [| 8 Cashier Winnings

WINNER’S name, address, and ZIP code 9 Winner's taxpayer identification no. ff 10 Window

ha First 1. ~ 12 Second |.D |
Copy 2—

To be fited with
winner’s state
income tax return, if
Under penalties of perjury, | decare that, tothe best of my knowledge and belief. the name, addres, and taxpayer identification number that Ihave furnished correctly dentiy | required.

ime asthe recipient ofthis payment and any payments from identical wagers, and that no other person 1s entitled to any part of these payments

13 State/Payer’s state identification no, f 14 State income tax withheld

Signature > Date >
Form W-2G Department of the Treasury - Internal Revenue Service

LJ CORRECTED (it checked)

OMB No. 1545-0238

PAYER'S name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income tax withheld
identification number 1990
3 Type of wager ‘4 Date won ,
f ' Statement for
- iu i Recipients of
5 Transaction 6 Race Certain
a Gambling
7 Winnings from identical wagers ashier . :
® 8 Winnings
WINNER'S name, address, and ZIP code {9 Winners taxpayer dentifcation no. J 10 Window
11 First |.D 12 Second !.D.
Copy 2—
13 State/Payer's state identification no. {14 State income tax withheld To be filed with
winner's state

income tax return, if
Under penalties of perjury, | declare that, tothe best of my knowledge and belief, the name, address, and texpayer identification number that | have furnished corectly dentity required,
me as the recipient of this payment and any payments from identical wagers, and that no other person 1s entitied to any part of these payments.

L Signature > Date >
Form W-2G Department of the Treasury - Internal Revenue Service
LI CORRECTED (itchecked)
PAYER’S name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income taxwithheld J OMB No. 1545.0238
identification number 4990
3 Type of wager 4 Date won
Statement for
Recipients of
5 Transaction 6 Race Certain
7 Gambling
7 Winnings from identical wagers ‘ashier ee
| = Winnings
WINNER'S name, address, and ZIP code 9 Winners taxpayer dentifcation no. J 10 Window
11 First 1.0. 12 Second |.D.
Copy 2—
13 State/Payer’s state identification no. J 14 State income tax withheld To be filed with
winner's state
i income tax return, if
Under penalties of perjury, | declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identity] required.
me as the recipient of this payment and any payments from identical wagers, and that no other person 1s entitled to any part of these payments.
Signature > Date >

Form W-2G Department of the Treasury - Internal Revenue Service


3232 C) corrected
Typeorprint PAYERSname 1 Gross winnings 2 Federalincometaxwithheld J OMB No. 1545-0238
Street address 3 Type of wager Date woh 1990
: : Statement for
City, state, and ZIP cod - ~ Recipients of
ity, state, and ZIP code 5 Transaction 6 Race Certain
— Gamblin;
Federal identification number 7 Winnings from identical wagers [| 8 Cashier Winnings
Type or print WINNER'S name ‘9 Winner's taxpayer dentifiction no. [ 10 Window For Paperwork
Reduction Act Notice
Street address Ty First 1. 12 Second Lb and instructions for
completing this form,
see Instructions for
City, state, and ZIP code 113 State/Payer’s state identification no. ff 14 State income tax withheld Forms 1099, 1098,
5498, and W-2G.

Signature >

Under penalties of perjury, declare that to the best of my knowledge and belief, the name. address. and taxpayer identification number that | have furnished correctly identity
‘me as the recipient of this payment and any payments from identical wagers, and that no other person is entitlec to any part of these payments,

Date>

Copy A
For Internal Revenue
Service Center

Form W-2G

3232

[7 CORRECTED

Department of the Treas:

Type or print PAYER’S name.

1 Gross winnings

2 Federal income tax withheld

ry - Internal Revenue Service

OMB No. 1545-0238

1990

City, state, and ZIP code

113 State/Payer's state identification no

14 State income tax withheld

Street address 13 Type of wager 4 Date won

: Statement for

u Recipients of
City, state, and ZIP code 5 Transaction 6 Race Certain
Federal identification numbé fi 8 Cash Gambling

eral identification number 7Wi identical r ant
innings from identical wagers ashie Winnings
Type or print WINNER'S name 9 Winners taxpayer identification no. 10 Window For Paperwork
Reduction Act Notice

Street address hi Fist 1D 12 Second 1. and instructions for

completing this form,
see Instructions for
Forms 1099, 1098,
5498, and W-2G.

Under penalties of paruy,V declare tha, tothe best of my knowledge and bevel. the name, address. and taxpayer entiation number Thal Ihave furnish correctly Went Cony A
me as the recipient of this payment and any payments from identical wagers, and that no other person 1s entitled to any part ofthese payments PY
For Internal Revenue
Signature > Date> Service Center
Form W-2G Department of the Treasury - Internal Revenue Service

3232 C) corrected
Type or print PAYER’S name T Gross winnings 2 Federal income tax withheld J OMB No. 1545-0238
Street address 3 Type of wager 4 Date won 1990
: Statement for
Recipients of
City, state, and ZIP code 5 Transaction | 6 Race Certain
Federal identification numb Tw 7 36 Gambling
ification number in identical ? lami
innings from identical wagers | 8 Cashier Winnings
Type or print WINNER'S name 9 Winner's taxpayer dentification no. [10 Window For Paperwork
Reduction Act Notice
Street address 1 First |.D 12 Second I.D. and instructions for
completing this form,
{— see Instructions for
City, state, and ZIP code 113 State/Payer’s state identification no. ff 14 State income tax withheld Forms 1099, 1098,
5498, and W-2G.

Signature >

‘Under penalties of perjury, | declare tha, fo the best of my knowledge and belief, the name. address, and taxpayer dentfication number that | have furnished correctly entity
me as the recipient of this payment and any payments from identical wagers. and thal no other person is entitled to any part of these payments.

Date >

Copy A
For Internal Revenue
Service Center

Form W-2G

Department of the Treas:

ury - Internal Revenue Service


C1 corRECTED

PAYER’S name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income taxwithheld J OM® No. 1545-0238
identification number 1990
x
3 Type of wager 4 Date won | io
A Statement for
: { Recipients of
5 Transaction 6 Race Certain
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address, and ZIP code 9 Winner's taxpayer enifcation no. ff 10 Window
11 First 1.D. 12 Second |.0.
|
113 State/Payer’s state identification no. J 14 State income tax withheld
I Copy D
‘Under penalties of perjury, | deciare that. to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identify
ime as the recipient of this payment and any payments from identical wagers, and that no other person 1s entitled to any part of these payments. For Payer
Signature > Date >
Form W-2G Department of the Treasury - Internal Revenue Service
CI correcTep
PAYER’S name, address, ZIP code, and Federal 1 Gross winnings 2 Federalincome taxwithheld J OMBNo. 1545-0238
identification number 1990
3 Type of wager 4 Date won
: : Statement for
u i Recipients of
| 5 Transaction 6 Race Certain
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address, and ZIP code a identification no, J 10 Window
|
11 First 1.0. 12 Second I.0.
113 State/Payer's state identification no. ff. 14 State income tax withheld
Copy D
Under penalties of perjury, | declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly rdentity
me as the recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part of these payments, For Payer
L Signature > Date >
Form W-2G Department of the Treasury - Internal Revenue Service

C] corRECTED

| PAYER’S name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income tax withheld J OMB No. 1545.0238
identification number 1990
‘3 Type of wager 4 Date won
: : Statement for
i u Recipients of
5 Transaction | 6 Race Certain
—{ Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address, and ZIP code 9 Winner’ taxpayer Wentfication no. J 10 Window
11 First 1.0. 12 Second I.D.
113 State/Payer's state identification no. 14 State income tax withheld
}_ Copy D
Under penalties of perjury, | declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identity
me as the recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part of these payments. For Payer
Signature > Date >

Form W-2G

Department of the Treasury - Internal Revenue Service


Instructions to Recipient

Box 1.—The payer must report gambling winnings on Form W-2G if
you receive:

(1) $600 or more in gambling winnings from

(a) Horse racing, dog racing, jat alai, state lotteries, and
other wagering transactions not specifically referred to
in (1)(b), (2), or (3), and the winnings are at least 300
times the amount of the wager; or
(b) Lotteries, raffles, sweepstakes, wagering pools, or
drawings, such as those held by churches or civic
organizations;
(2) $1,200 or more of gambling winnings from bingo or slot
machines; or
(3) $1,500 or more of proceeds (the amotnt of winnings less
the amount of the wager) from keno.

Instructions to Recipient

Box 1:—The payer must report gambling winnings on Form W-2G if
you receive:

(1) $600 or more in gambling winnings from:

(a) Horse racing, dog racing, ja1 alai, state lotteries, and
other wagering transactions not specifically referred to
in (1)(b), (2), oF (3), and the winnings are at least 300
times the amount of the wager; or
(b) Lotteries, raffles, sweepstakes, wagering pools, or
drawings, such as those held by churches or civic
organizations;
(2) $1,200 or more of gambling winnings from bingo or slot
machines; or
(3) $1,500 or more of proceeds (the amount of winnings less
the amount of the wager) from keno.

Instructions to Recipient

Box 1.—The payer must report gambling winnings on Form W-2G if
you receive:

(1) $600 or more in gambling winnings from:

(a) Horse racing, dog racing, jal alai, state lotteries, and
other wagering transactions not specifically referred to
in (1)(b), (2), or (3), and the winnings are at least 300
times the amount of the wager; or

(b) Lotteries, raffles, sweepstakes, wagering pools, or
drawings, such as those held by churches or civic
organizations;

(2) $1,200 or more of gambling winnings from bingo or slot
machines; or

(3) $1,500 or more of proceeds (the amount of winnings less
the amount of the wager) from keno,

Box 2.—Any Federal income tax withheld on these winnings 1s
shown in this box. Federal income tax must be withheld at the
rate of 20% on certain winnings less the wager Whether
Federal income tax must be withheld depends on the type and
amount of the winnings, including winnings from identical
wagers, and the odds

In addition, if you did not provide your social security
number to the payer, the amount in this box may be backup
withholding at a 20% rate.

Include the amount shown in Box 2 on your tax return as
Federal income tax withheld.
Signature.—You must sign Form W-2G if you are the only
person entitled to the winnings and the winnings are subject to
regular gambling withholding
Other Winners, —The payer should ask you to prepare Form
5754, Statement by Person(s) Receiving Gambling Winnings, if
another person is entitled to any part of these winnings

Box 2.—Any Federal income tax withheld on these winnings is
shown in this box. Federal income tax must be withheld at the
rate of 20% on certain winnings less the wager. Whether
Federal income tax must be withheld depends on the type and
amount of the winnings, including winnings from identical
wagers, and the odds.

In addition, if you did not provide your social security
number to the payer, the amount in this box may be backup
withholding at a 20% rate

Include the amount shown in Box 2 on your tax return as
Federal income tax withheld.
Signature.—You must sign Form W-2G if you are the only
person entitled to the winnings and the winnings are subject to
regular gambling withholding.
Other Winners. —The payer should ask you to prepare Form
5754, Statement by Person(s) Receiving Gambling Winnings, if
another person is entitled to any part of these winnings.

Box 2.—Any Federal income tax withheld on these winnings is
shown in this box. Federal income tax must be withheld at the
rate of 20% on certain winnings less the wager Whether
Federal income tax must be withheld depends on the type and
amount of the winnings, including winnings from identical
wagers, and the odds,

In addition, if you did not provide your social security
number to the payer, the amount in this box may be backup
withholding at a 20% rate

Include the amount shown in Box 2 on your tax return as
Federal income tax withheld.

Signature.—You must sign Form W-2G if you are the only
person entitled to the winnings and the winnings are subject to.
regular gambling withholding

Other Winners.—The payer should ask you to prepare Form

5754, Statement by Person(s) Receiving Gambling Winnings, if
another person is entitled to any part of these winnings




CI corRECTED

OMB No. 1545-0238

PAYER’S name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income tax withheld
identification number 4990
3 Type of wager ‘Date won
: : Statement for
a : Recipients of
5 Transaction 6 Race Certain
= Gambling
7 Winnings from identical wagers 8 Cashier . .
8 e Winnings
WINNER'S name, address, and ZIP code ‘9 Winner's taxpayer dentifcation no. 10 Window
1 First | D 12 Second |.
Copy 1—
113 State/Payer's state dentification no, ff 14 State income tax withheld For State Tax
I Department
Under penalties of perjury, | declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identify
ime as the recipient of this payment and any payments from identical wagers, and that no other person 1s entitled to any part of these payments.
Signature > Date > 7
Form W-2G Department of the Treasury - Internal Revenue Service

CT) corrected

PAYER’S name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income tax withheld OMBNo. 1545-0238
identification number 1990
3 Type of wager 4 Date won
: : Statement for
. u Recipients of
5 Transaction 6 Race Certain
; a Gambling
7 Winnings from identical wagers [| 8 Cashier Se
es 8 Winnings
WINNER'S name, address, and ZIP code 9 Winner's taxpayer entification no, [10 Window
11 First | D. 12 Second |.D.
Copy 1—
13 State/Payer’s state identification no, ff 14 State income tax withheld For State Tax
Department
Under penalties of perjury, | declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identify
me as the recipient of this payment and any payments from identical wagers, and that no other person 1s entitled to any part of these payments.
Signature > Date>
Form W-2G Department of the Treasury - internal Revenue Service

CJ corRecTED

PAYER’S name, address, ZIP code, and Federal 7 Gross winnings T 2 Federal income taxwithheld J OMB No. 1545.0238
identification number 1990
3 Type of wager 4 Date won
: Hl Statement for
i Recipients of
5 Transaction Race Certain
Gambling
7 Winnings from identical wagers {| 8 Cashier Winnings
| WINNER'S name, address, and ZIP code ‘9 Winner's taxpayer identification no, 10 Window
11 First | D. 12 Second |.D.
Copy 1—
113 State/Payer's state identification no. ff 14 State income tax withheld For State Tax
Department

Under penalties of perjury. | deciare that, to the best of my knowledge and belie, the name, address, and taxpayer identification number that | have furnished correctly identify
me as the recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part ofthese payments.

Signature > Date >
Form W-2G Department of the Treasury - Internal Revenue Service