3232 CORRECTED

OMB No. 1545-0238 PAYER’S name 1 Gross winnings 2 Federal income tax withheld

Street address 3 Type of wager 4 Date won

Certain

Gambling

Winnings

City, state, and ZIP code 5 Transaction 6 Race

Federal identification number 7 Winnings from identical wagers 8 Cashier

For Paperwork

Reduction Act Notice

and instructions for

completing this form,

see Instructions for

Forms 1099, 1098,

5498, and W-2G.

WINNER’S name 9 Winner’s taxpayer identification no. 10 Window

Street address (including apt. no.) 11 First I.D. 12 Second I.D.

City, state, and ZIP code 13 State/Payer’s state identification no. 14 State income tax withheld

File with Form 1096.

Under penalties of perjury, I declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that I 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. Copy A

Signature © Date ©

Form W-2G Cat. No. 10138V Department of the Treasury - Internal Revenue Service

For Internal Revenue

Service Center

CORRECTED

OMB No. 1545-0238 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

Certain

Gambling

Winnings

5 Transaction 6 Race

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 I.D. 12 Second I.D.

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 I 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.

Copy 1—

Signature © Date ©

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

For State Tax

Department

CORRECTED (if checked)

OMB No. 1545-0238 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

Certain

Gambling

Winnings

5 Transaction 6 Race

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 I.D. 12 Second I.D.

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 I 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.

Copy B

Signature © Date ©

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

Report this income on

your Federal tax return. If

this form shows tax was

withheld, attach this copy

to your return.

This information is

being furnished to

the Intenal Revenue

Service.

CORRECTED (if checked)

OMB No. 1545-0238 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

Certain

Gambling

Winnings

5 Transaction 6 Race

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 I.D. 12 Second I.D.

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 I 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. Copy C

Signature © Date ©

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

This is important tax

information and is being

furnished to the Internal

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.

For Winner’s

Records
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.

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

(a) 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

Lotteries, raffles, sweepstakes, wagering pools, or Federal income tax withheld.

drawings, such as those held by churches or civic

organizations;

(b)

Signature.—You must sign Form W-2G if you are the only person

entitled to the winnings and the winnings are subject to regular

$1,200 or more of gambling winnings from bingo or slot gambling withholding.

machines; or

(2)

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. $1,500 or more of proceeds (the amount of winnings less

the amount of the wager) from keno.

(3)
CORRECTED (if checked)

OMB No. 1545-0238 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

Certain

Gambling

Winnings

5 Transaction 6 Race

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 I.D. 12 Second I.D.

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 I 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.

Copy 2

Signature © Date ©

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

To be filed with

winner’s state

income tax return,

if required.

CORRECTED

OMB No. 1545-0238 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

Certain

Gambling

Winnings

5 Transaction 6 Race

7 Winnings from identical wagers 8 Cashier

For Paperwork

Reduction Act Notice

and instructions for

completing this form,

see Instructions for

Forms 1099, 1098,

5498, and W-2G.

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

11 First I.D. 12 Second I.D.

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 I 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. Copy D

Signature © Date ©

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

For Payer