Fillable Printable Form W2G

Form W2G

3232

CORRECTED

OMB No. 1545-0238

PAYER’S name

Federal income tax withheld

Gross winnings

Street address

Date won

Type of wager

Certain

Gambling

Winnings

Race

Transaction

City, state, and ZIP code

Federal identification number

Cashier

Winnings from identical wagers

For Privacy Act and

Paperwork Reduction Act

Notice, see the 2009

General Instructions for

Forms 1099, 1098, 3921,

3922, 5498, and W-2G.

Window

WINNER’S name

Winner’s taxpayer identification no.

Street address (including apt. no.)

First I.D.

Second I.D.

City, state, and ZIP code

State/Payer’s state identification no.

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

Date

Signature

Department of the Treasury - Internal Revenue Service

Form W-2G

Cat. No. 10138V

For Internal Revenue

Service Center

Form W-2G

Telephone number

Note: Form W-2G is printed black & white, not color like the other W-2s.

CORRECTED

OMB No. 1545-0238

Federal income tax withheld

Gross winnings

Date won

Type of wager

Race

Transaction

Cashier

Winnings from identical wagers

Window

Winner’s taxpayer identification no.

First I.D.

Second I.D.

State/Payer’s state identification no.

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.

Date

Signature

Department of the Treasury - Internal Revenue Service

Form W-2G

PAYER’S name, address, ZIP code, federal identification

number, and telephone number

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

Copy 1

For State Tax

Department

Certain

Gambling

Winnings

Form W-2G

CORRECTED (if checked)

OMB No. 1545-0238

Federal income tax withheld

Gross winnings

Date won

Type of wager

Race

Transaction

Cashier

Winnings from identical wagers

Window

Winner’s taxpayer identification no.

First I.D.

Second I.D.

State/Payer’s state identification no.

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.

Date

Signature

Department of the Treasury - Internal Revenue Service

Form W-2G

PAYER’S name, address, ZIP code, federal identification

number, and telephone number

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

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.

This information is

being furnished to

the Internal

Revenue Service.

Certain

Gambling

Winnings

Form W-2G

CORRECTED (if checked)

OMB No. 1545-0238

Federal income tax withheld

Gross winnings

Date won

Type of wager

Race

Transaction

Cashier

Winnings from identical wagers

Window

Winner’s taxpayer identification no.

First I.D.

Second I.D.

State/Payer’s state identification no.

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.

Date

Signature

Department of the Treasury - Internal Revenue Service

Form W-2G

PAYER’S name, address, ZIP code, federal identification

number, and telephone number

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

Copy C

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

Certain

Gambling

Winnings

Form W-2G

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 25% on certain winnings less the wager.

Instructions to Winner

Certain winnings that are not subject to 25% withholding

may be subject to backup withholding at a 28% rate 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.

Box 1. The payer must furnish a Form W-2G to you if you receive:

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

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;

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.

5. Any other gambling winnings subject to federal income

tax withholding.

CORRECTED (if checked)

OMB No. 1545-0238

Federal income tax withheld

Gross winnings

Date won

Type of wager

Race

Transaction

Cashier

Winnings from identical wagers

Window

Winner’s taxpayer identification no.

First I.D.

Second I.D.

State/Payer’s state identification no.

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.

Date

Signature

Department of the Treasury - Internal Revenue Service

Form W-2G

PAYER’S name, address, ZIP code, federal identification

number, and telephone number

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

Copy 2

Attach this copy

to your state

income tax return,

if required.

Certain

Gambling

Winnings

Form W-2G

CORRECTED

OMB No. 1545-0238

Federal income tax withheld

Gross winnings

Date won

Type of wager

Race

Transaction

Cashier

Winnings from identical wagers

Window

Winner’s taxpayer identification no.

First I.D.

Second I.D.

State/Payer’s state identification no.

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.

Date

Signature

Department of the Treasury - Internal Revenue Service

Form W-2G

PAYER’S name, address, ZIP code, federal identification

number, and telephone number

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

For Privacy Act and

Paperwork Reduction Act

Notice, see the 2009

General Instructions for

Forms 1099, 1098, 3921,

3922, 5498, and W-2G.

Copy D

For Payer

Certain

Gambling

Winnings

Form W-2G

Due dates. Furnish Copies B and C of this form to the

winner by February 1, 2010.

Instructions for Payers

General and specific form instructions are provided as

separate products. The products you should use to

complete Form W-2G are the 2009 General Instructions for

Forms 1099, 1098, 3921, 3922, 5498, and W-2G and the

2009 Instructions for Forms W-2G and 5754. To order

these instructions and additional forms, visit the IRS

website at www.irs.gov, or call 1-800-TAX-FORM

(1-800-829-3676).

File Copy A of this form with the IRS by March 1, 2010.

If you file electronically, the due date is March 31, 2010.

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.

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 2009 Instructions for

Forms W-2G and 5754.

Withholding. You may be required to withhold federal

income tax from cash or noncash gambling winnings. See

the 2009 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 304-267-3367

(not toll free).