5754 Statement by Person(s) Receiving Gambling Winnings

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Date

5754

Form
(Rev. August 2005)

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5754, PAGE 1 of 2
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Date

Signature

O.K. to print
Revised proofs
requested

Statement by Person(s) Receiving Gambling Winnings
䊳

Recipients of gambling winnings should see the instructions on the back of this form.

䊳

Department of the Treasury
Internal Revenue Service
Date won

Part I

Action

Payers of gambling winnings should see the separate Instructions for Forms W-2G
and 5754.
Type of winnings

Game number

OMB No. 1545-0239
Return to payer. Do not
send to the IRS.

Machine number

Race number

Person to Whom Winnings Are Paid
Name

Address

Taxpayer identification number

Part II

Other I.D.

Amount received

Federal income tax
withheld

Persons to Whom Winnings Are Taxable (continued on page 2)
(a) Name

(b) Taxpayer
identification number

(c) Address

(d) Amount won

(e) Winnings from
identical wagers

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

䊳

For Privacy Act and Paperwork Reduction Act Notice, see back of form.

Date

䊳

Cat. No. 12100R

Form

5754

(Rev. 8-2005)

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5754, PAGE 2 of 2
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 5754 (Rev. 8-2005)

Part II

Page

2

Persons to Whom Winnings Are Taxable (continued from page 1)
(a) Name

(b) Taxpayer
identification number

Instructions for Recipient of Gambling
Winnings
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.
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.
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.
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

(c) Address

(e) Winnings from
identical wagers

(d) Amount won

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. We may
also disclose this information to other countries under a
tax treaty, to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism. If you fail to
provide this information in a timely manner, you may be
subject to penalties.
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 section 6103.
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 Internal Revenue Service, Tax Products
Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
Constitution Avenue, NW, IR-6406, Washington, DC
20224. Do not send this form to this address. Instead,
return it to the payer.

Form

5754

(Rev. 8-2005)