Form 5754 Statement by Person(s) Receiving Gambling Winnings

5754

Form
(Rev. December 2008)
Department of the Treasury
Internal Revenue Service

Statement by Person(s) Receiving Gambling Winnings
©

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

©

Date won

Part I

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

©

For Paperwork Reduction Act Notice, see back of form.

Date

©

Cat. No. 12100R

Form

5754

(Rev. 12-2008)

Form 5754 (Rev. 12-2008)

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 two or more people sharing the
winnings, such as by sharing 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.

(c) Address

(e) Winnings from
identical wagers

(d) Amount won

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 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 two or more people sharing
the winnings, such as by sharing the same winning ticket.
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-6526, Washington, DC
20224. Do not send this form to this address. Instead,
return it to the payer.

Form

5754

(Rev. 12-2008)