Form W-2G Certain Gambling Winnings

CORRECTED

3232
PAYER’S name

1 Gross winnings

2 Federal income tax withheld

Street address

3 Type of wager

4 Date won

City, state, and ZIP code

5 Transaction

6 Race

7 Winnings from identical wagers

8 Cashier

OMB No. 1545-0238

2011

Form W-2G
Federal identification number
WINNER’S name

Telephone number

Certain
Gambling
Winnings

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

For Privacy Act and
Paperwork Reduction Act
Notice, see the 2011
General Instructions for
Certain Information
Returns.
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.

Signature ▶
Form W-2G

Date ▶
Cat. No. 10138V

Copy A
For Internal Revenue
Service Center

Department of the Treasury - Internal Revenue Service

CORRECTED
PAYER’S name, address, ZIP code, federal identification
number, and telephone number

1 Gross winnings

2 Federal income tax withheld

3 Type of wager

4 Date won

5 Transaction

6 Race

7 Winnings from identical wagers

8 Cashier

OMB No. 1545-0238

2011

Form W-2G

WINNER’S name, address (including apt. no.), and ZIP code

Certain
Gambling
Winnings

9 Winner’s taxpayer identification no. 10 Window
11 First I.D.

12 Second I.D.

Copy 1
13 State/Payer’s state identification no. 14 State income tax withheld

For State Tax
Department

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.

Signature ▶
Form W-2G

Date ▶
Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)
PAYER’S name, address, ZIP code, federal identification
number, and telephone number

1 Gross winnings

2 Federal income tax withheld

3 Type of wager

4 Date won

5 Transaction

6 Race

7 Winnings from identical wagers

8 Cashier

OMB No. 1545-0238

2011

Form W-2G

WINNER’S name, address (including apt. no.), and ZIP code

Certain
Gambling
Winnings

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.

Signature ▶
Form W-2G

Date ▶

This information is
being furnished to
the Internal
Revenue Service.

Copy B
Report this income on your
federal tax return. If this
form shows federal income
tax withheld in box 2, attach
this copy to your return.

Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)
PAYER’S name, address, ZIP code, federal identification
number, and telephone number

1 Gross winnings

2 Federal income tax withheld

3 Type of wager

4 Date won

5 Transaction

6 Race

7 Winnings from identical wagers

8 Cashier

OMB No. 1545-0238

2011

Form W-2G

WINNER’S name, address (including apt. no.), and ZIP code

Certain
Gambling
Winnings

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.

Signature ▶
Form W-2G

Date ▶

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.

Copy C
For Winner’s
Records

Department of the Treasury - Internal Revenue Service

Instructions to Winner
Box 1. The payer must furnish a Form W-2G to you if you
receive:
1. $1,200 or more in gambling winnings from bingo or slot
machines;
2. $1,500 or more in proceeds (the amount of winnings minus
the amount of the wager) from keno;
3. More than $5,000 in winnings (reduced by the wager or
buy-in) from a poker tournament;
4. $600 or more in gambling winnings (except winnings from
bingo, keno, slot machines, and poker tournaments) and the
payout is at least 300 times the amount of the wager; or
5. Any other gambling winnings subject to federal income tax
withholding.
Generally, report all gambling winnings on the “Other income”
line of Form 1040. You can deduct gambling losses as an
itemized deduction, but you cannot deduct more than your
winnings. Keep an accurate record of your winnings and losses,
and be able to prove those amounts with receipts, tickets,
statements, or similar items that you have saved. For additional
information, see Pub. 529, Miscellaneous Deductions, and Pub.
525, Taxable and Nontaxable Income.

Box 2. Any federal income tax withheld on these winnings is
shown in this box. Federal income tax must be withheld on
certain winnings less the wager.
Certain winnings that are not subject to regular gambling
withholding may be subject to backup withholding if you did not
provide your federal identification number to the payer.
Include the amount shown in box 2 on your Form 1040 as
federal income tax withheld. See Pub. 505, Tax Withholding and
Estimated Tax, for additional information.
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. Return the signed form to the payer, who
will give you your copies.
Other winners. Prepare Form 5754, Statement by Person(s)
Receiving Gambling Winnings, if another person is entitled to
any part of these winnings. Give Form 5754 to the payer, who
will use Form 5754 to prepare Form W-2G for each person
listed as a winner.

CORRECTED (if checked)
PAYER’S name, address, ZIP code, federal identification
number, and telephone number

1 Gross winnings

2 Federal income tax withheld

3 Type of wager

4 Date won

5 Transaction

6 Race

7 Winnings from identical wagers

8 Cashier

OMB No. 1545-0238

2011

Form W-2G

WINNER’S name, address (including apt. no.), and ZIP code

Certain
Gambling
Winnings

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.

Signature ▶
Form W-2G

Copy 2
Attach this copy
to your state
income tax return,
if required.

Date ▶
Department of the Treasury - Internal Revenue Service

CORRECTED
PAYER’S name, address, ZIP code, federal identification
number, and telephone number

1 Gross winnings

2 Federal income tax withheld

3 Type of wager

4 Date won

5 Transaction

6 Race

7 Winnings from identical wagers

8 Cashier

OMB No. 1545-0238

2011

Form W-2G

WINNER’S name, address (including apt. no.), and ZIP code

Certain
Gambling
Winnings

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.

Signature ▶
Form W-2G

Date ▶

For Privacy Act and
Paperwork Reduction Act
Notice, see the 2011
General Instructions for
Certain Information
Returns.

Copy D
For Payer

Department of the Treasury - Internal Revenue Service

Instructions for Payer
General and specific form instructions are provided as
separate products. The products you should use to
complete Form W-2G are the 2011 General Instructions for
Certain Information Returns and the 2011 Instructions for
Forms W-2G and 5754. To order these instructions and
additional forms, visit IRS.gov or call 1-800-TAX-FORM
(1-800-829-3676).

Foreign winners. Use Form 1042-S, Foreign Person’s U.S.
Source Income Subject to Withholding, to report gambling
winnings paid to nonresident aliens and foreign corporations.
See the Instructions for Form 1042-S. You may be required
to withhold federal income tax at a 30% rate. See Pub. 515,
Withholding of Tax on Nonresident Aliens and Foreign
Entities.

Due dates. Furnish Copies B and C of this form to the
winner by January 31, 2012.

Form 5754. If the person receiving the winnings is not the
actual winner or is a member of a group of winners, see the
instructions for Form 5754, Statement by Person(s)
Receiving Gambling Winnings, in the 2011 Instructions for
Forms W-2G and 5754.

File Copy A of this form with the IRS by February 28, 2012.
If you file electronically, the due date is April 2, 2012.
Withholding. You may be required to withhold federal
income tax from cash or noncash gambling winnings. See
the 2011 Instructions for Forms W-2G and 5754 for the rates.

Need help? If you have questions about reporting on Form
W-2G, call the information reporting customer service site
toll free at 1-866-455-7438 or 304-263-8700 (not toll free).
For TTY/TDD equipment, call 304-579-4827 (not toll free).
The hours of operation are Monday through Friday from
8:30 a.m. to 4:30 p.m., Eastern time.