CJ 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

1991

3 Type of wager “4 Date won
EE i : Certain
ransaction face +
: Gambling
Winnings
7 Winnings from identical wagers | 8 Cashier
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winners taxpayer identification no. | 10 Window This information is
being furnished to
11 First 1.D. 12 Second 1.0. the Internal Revenue

Service.

13 State/Payers 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 identify
ime 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,

Copy B

Report this income on
your Federal tax return. If
this form shows tax was

withheld, attach this copy
Signature > Date> to your return.
Form W-2G Department of the Treasury - Internal Revenue Service

im CORRECTED (if checked)

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

7 Gross winnings

2 Federal income tax withheld

OMB No. 1545-0238

1991

3 Type of wager “4 Date won
—— & : Certain
Transaction
ace Gambling
- Winnings
7 Winnings from identical wagers | 8 Cashier
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winners taxpayer identification no. | 10 Window This information is
being furnished to
11 First 1D. 12 Second |.D. the Internal Revenue

Service.

13 State/Payers state identification no.
L

14 State income tax withheld

Signature >

‘Under penalties of perjury, | declare that, to the best of my knowledge and belief, tne 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 of these payments.

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 (if checked)

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

1 Gross winnings

2 Federal income tax withheld

OMB No. 1545-0238,

1991

3 Type of wager “4 Date won
tT - : Certain
Tansaction face :
Gambling
Winnings
7 Winnings from identical wagers | 8 Cashier
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winner's taxpayer identification no. | 10 Window This information is
being furnished to
11 First 1D. 12 Second I.D. the Internal Revenue
Service.
13 State/Payer’s state identification no. | 14 State income tax withheld Copy B
Report this income on
der penalties of perjury, | declare that, tothe best of my knowledge and belt, the name, address, and taxpayer identification number that | hae furnished correctly identify | Your Federal tax return. If
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. this form shows tax was
withheld, attach this copy
Signature > Date > to your return.

Form W-2G.

Department of the Treasury - Internal Revenue Service




(J CORRECTED (if checked)

OMB No. 1545-0238,

PAYER’S name, address, ZIP code, and Federal T Gross winnings 2 Federal Income tax withheld
identification number 1991
3 Type of wager 4 Date won
sian a Certain
ransaction face .
Gambling
innings
7 Winnings from identical wagers | 8 Cashier wi n 8
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winner's taxpayer identification no. 10 Window This is important tax
information and is being
furnished to the Internal
Revenue Service. If you are
11 First |.D. 12 Second |.D. required to file a return, a
negligence penalty or other
sanction may be imposed on
¢ ificatic ). you if this income is taxable
13 State/Payer's state identification no. | 14 State income tax withheld Pld the IRS determines that
it has not been reported,

Under penalties of perjury, 1 decare that, tothe best of my knowledge and belie, the name, address, and taxpayer identification number that ! have furnished correctly identify | Copy C
ime as the recipient of this payment and sny payments from identical wagers, and that no other person is entitled to any part of these payments,

For Winner's
Signature > Date > Records :
Form W-2G Department of the Treasury - Internal Revenue Service

oO CORRECTED (if checked)
name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income tax withheld

OMB No. 1545-0238

identification number 1991
3 Type of wager 4 Date won
i | Certain
5 Transaction 6 Race Gambling
Winnings

7 Winnings from identical wagers | 8 Cashier

WINNER'S name, address (Including apt. no.), and ZIP code | 9 Winner's taxpayer identification no. | 10 Window This is important tax
information and is being
fuurished to ‘the Internal
Revenue Service. If you are
11 First LD. 12 Second .D. required to file a return, @
negligence penalty or other
sanction may be imposed on
7 fication no. | 14 State i you if this income is taxable
13 State/Payers state identification no. ate income tax withheld yout this income is taxable,
ithas not been reported.

Under penalties of perjury, | declare that, tothe best of my knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identity | Copy C
ime 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 Winner's
Signature > Date > Records
Form W-2G Department of the Treasury - Internal Revenue Service

C1 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 1991
3 Type of wager ‘Date won
Tamed ua u Certain
ransaction face .
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winners taxpayer identification no. | 10 Window This is important tax
information and is bein,
furnished to the Internal
11 First .D. 12 Second 1D. peeedte carton.
negligence penalty or other
sanction may be imposed on
13 State/Payer’s state identification no. | 14 State income tax withheld yout this income is taxable
it has not been reported.

Under penalties of perjury, I declare that, tothe best of my knowledge and belief, the name, address, and taxpayer identification number that Ihave furnished correctly identity | Copy C
‘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 Winner's

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





(1 CORRECTED (it checked)

PAYER’S name, address, ZIP code, and Federal 1 Gross winnings 2 Federal income tax withheld | OMBNo. 1545-0238
identification number 1 9g 1
‘3 Type of wager Date won
se mm : Certain
ransaction face ;
Gambling
Winnings

7 Winnings from identical wagers | 8 Cashier

WINNER'S name, address (including apt. no.), and ZIP code | 9 Winer’ taxpayer identification no. | 10 Window

11 First 1.0. 12 Second I.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, to the best of my Knowledge and belief, the name, address, and taxpayer identification number that | have furnished correctly identify | required,
ime 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.

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

CJ CORRECTED (if checked)

PAYER'S name, address, ZIP code, and Federal 7 Gross winnings 2 Federalincome tax withheld | OMBNo. 1545-0238
identification number 1991
3 Type of wager 4 Date won
i Certain
5 Transaction 6 Race
Gambling
Winnings

7 Winnings from identical wagers | 8 Cashier

WINNER'S name, address (including apt. no.), and ZIP code | 9 Winners taxpayer identification no. | 10 Window

11 First LD. 12 Second .D.
Copy 2—

13 State/Payers 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, to the best of my knowledge and belief the name, address, and taxpayer identification number that Ihave furnished corectly identify | required,
‘me asthe recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part of these payments.

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

C1 CORRECTED (if checked)

OMB No, 1545-0238

PAYER’S name, address, ZIP code, and Federal T Gross winnings 2 Federal income tax withheld
identification number 1991
3 Type of wager 4 Date won
Timed me : Certain
Tansaction face
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winner’ taxpayer identification no. | 10 Window
11 First .D. 12 Second I.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 belie, 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 ather person is entitled to any part ofthese payments,

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



3232

C] correcTeD

Type or print PAYER’S name

1 Gross winnings

2 Federal income tax withheld | OMB No. 1545-0238

1991

City, state, and ZIP code

Street address ‘3 Type of wager ‘Date won
City, state, and ZIP code 3 Transacti G Race Certain
ity, state, ansaction
» Gambling
Federal identification number 7 Winnings from identical wagers | 8 Cashier Winnings
For Paperwork
Type or print WINNER'S name. ‘9 Winner's taxpayer identification no. | 10 Window Reduction Act Notice
and instructions for
i completing this form,
Street address (including apt. no.) 11 First LD. 12 Second I.D. Petri

see Instructions for
Forms 1099, 1098,

13 State/Payer's state identification no.

5498, and W-2G.
File with Form 1096.

14 State income tax withheld

Signature >

‘Under penalties of perjury, I declare tha, tothe best of my knowledge and belie, the name, address, and taxpayer identification number that! have furnished correctly identi | Cony A
meas the recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part of these payments py

For Internal Revenue

Date> Service Center

Form W-2G

a232

C1 correcteD

Department of the Treasury - Internal Revenue Service

Type or print PAYER’S name

1 Gross winnings

OMB No, 1545-0238

1991

2 Federal income tax withheld

City, state, and ZIP code

Street address B Type of wager ‘Date won
i i i
City, state, and ZIP code 5 Transaction 6 Race Ganbhag
Federal identification number 7 Winnings from identical wagers | & Cashier Winnings
For Paperwork
Type or print WINNER'S name ‘9 Winner's taxpayer identification no. | 10 Window Reduction Act Notice
and instructions for
Street address (including apt. no.) Ti Fist 1D. 12 Second. completing this form,

see Instructions for
Forms 1099, 1098,

13 State/Payer’s state identification no.

5498, and W-2G.
File with Form 1096.

14 State income tax withheld

Signature >

Under penalties of perjury, I declare that, tothe best of my knowledge and belie the name, address, and taxpayer identification number that | have furnished covet identify | Copy A
‘me as the recipient ofthis payment and any payments from identical wagers, and that no other person is entitled to any part of these payments. Py

For Internal Revenue

Date> Service Center

Form W-2G

3232

C1 correcTeD

Department of the Treasury - Internal Revenue Service

Type or print PAYER’S name

1 Gross winnings

OMB No. 1545-0238

1991

2 Federal income tax withheld

City, state, and ZIP code

Street address ‘3 Type of wager Date won
i
ertain
City, state, and ZIP code 5 Transaction 6 Race Gantling
Federal identification number 7 Winnings from identical wagers | 8 Cashier Winnings
For Paperwork
Type or print WINNER'S name ‘9 Winner's taxpayer identification no. | 10 Window Reduction Act Notice
and instructions for
completing this form,
Street address (including apt. no.) 11 First |.D. 12 Second |.D. see Pstroctions for

Forms 1099, 1098,

13 State/Payer’s state identification no.

5498, and W-2G.
File with Form 1096.

14 State income tax withheld

|_ Signature >

Under penalties of perjury, | decare tha, tothe best of my knowiedge and belie, the name, address, and taxpayer identification number that | have furnished crectyWdentity | Copy A
me asthe recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part ofthese payments. Py

For Internal Revenue

Date> Service Center

Form W-2G

Department of the Treasury - Internal Revenue Service


CJ correcTeD

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

1 Gross winnings

2 Federal income tax withheld

OMB No. 1545-0238

1991

3 Type of wager ‘4 Date won
: ! c. |

5 Transaction 6 Race ertain
Gambling

7 Winnings from identical wagers | 8 Cashier Winnings

WINNER'S name, address (including apt. no.), and ZIP code | 9 Winner's taxpayer identification no. | 10 Window For Paperwork

Reduction Act Notice

11 First |.D. 12 Second |.D. and instructions for

13 State/Payer's state identification no.

14 State income tax withheld

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

‘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 is entitled to any part of these payments. Copy D
For Payer
Signature > Date > y
Form W-2G Department of the Treasury - Internal Revenue Service

C] CORRECTED

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

1 Gross winnings

2 Federal income tax withheld

OMB No. 1545-0238

1991

13 State/Payer's state identification no.

14 State income tax withheld

3 Type of wager 4 Date won
8 Transaction Race Certain
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winner's taxpayer identification no. | 10 Window For Paperwork
Reduction Act Notice
11 First .D. 12 Second |.D. and instructions for

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

‘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

CI correcTeD

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

1 Gross winnings

2 Federal income tax withheld

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. Copy D
For Payer
Signature > Date> y
Form W-2G Department of the Treasury - Internal Revenue Service

OMB No. 1545-0238

1991

13 State/Payer's state identification no.

14 State income tax withheld

3 Type of wager ‘4 Date won
i : Certain
3 Transaction Race .
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winner's taxpayer identification no. | 10 Window For Paperwork
Reduction Act Notice
11 First LD. 12 Second .D. and instructions for

completing this form,
see Instructions for
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 identify
‘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.

Date>

Copy D
For Payer

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 it
you receive:

(2) $600 or more in gambling winnings from:
(a) Horse racing, dog racing, jai 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.

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, jai 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.

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:
(@) Horse racing, dog racing, jai 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 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
Tegular 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 adds

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.




CJ] CORRECTED

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

1 Gross winnings

2 Federal income tax withheld

OMB No. 1545-0238

1991

Signature >

‘Under penalties of perjury, 1 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 entitled to any part of these payments.

Date >

3 Type of wager 4 Date won
aoe a : Certain
ransaction ace
Gambling
, Winnings
7 Winnings from identical wagers | 8 Cashier
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winner's taxpayer identification no. | 10 Window
11 First |.D. 12 Second |.D.
Copy 1—
13 State/Payer's state identification no, | 14 State income tax withheld For State Tax
Department

Form W-2G

CI corRECTED

Department of the Treasury - Internal Revenue Service

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

1 Gross winnings

2 Federal income tax withheld

‘OMB No. 1545-0238

1991

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
‘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.

Date >

3 Type of wager 4 Date won
simak a : Certain
ransaction ace
Gambling
- Winnings
7 Winnings from identical wagers | 8 Cashier
WINNER'S name, address (including apt, no.), and ZIP code | 9 Winners taxpayer identification no. | 10 Window
11 First 1.D. 12 Second |.D.
Copy 1—
13 State/Payer's state identification no. | 14 State income tax withheld For State Tax
Department

Form W-2G

CJ CORRECTED

Department of the Treasury - Internal Revenue Service

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

1 Gross winnings

2 Federal income tax withheld

‘OMB No. 1545-0238

1991

|_ Signature >

Under penalties of perjury, | declare that, tothe best of my knowledge and belief, the name, address, and taxpayer iden
me asthe recipient ofthis payment and any payments from identical wagers, and that no other person is entitled to any part of these payments,

ication number that | have furnished correctly identify

Date>

3 Type of wager “Date won
er ja u Certain
ransaction ace
Gambling
7 Winnings from identical wagers | 8 Cashier Winnings
WINNER'S name, address (including apt. no.), and ZIP code | 9 Winners taxpayer identification no. | 10 Window
11 First 1.D. 12 Second |.D.
Copy 1—
13 State/Payer's state identification no. | 14 State income tax withheld For State Tax
Department

Form W-2G

Department of the Treasury - Internal Revenue Service