Form Il-5754 - Statement By Person Receiving Gambling Winnings - 2006
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Illinois Department of Revenue
IL-5754
Statement by Person Receiving Gambling Winnings
Who must complete this form?
Step 2: Who will receive winnings?
(Complete the following information
You must complete Form IL-5754 if you receive payment of Illinois lottery or
for each person receiving winnings.)
gambling winnings over $1,000. This form provides a record of who received
1 __ __ __ __ __ __ __ __ __
______________
winnings and to whom the winnings are taxable. The payer will use this
information to prepare Form W-2G.
Taxpayer identification number (SSN or FEIN)
Amount won
What if I need additional assistance?
________________________________________
If you need assistance, visit our website at tax.illinois.gov; call our Taxpayer
Assistance Division at 1 800 732-8866 or 217 782-3336; or call our TDD
Name
(telecommunications device for the deaf) at 1 800 544-5304. Our office hours
________________________________________
are 8 a.m. to 5 p.m.
Street address
Step 1: Winnings information
(Complete the following information.)
________________________________________
Date of payment ____/____/____ Type of winnings ____________________
City
State
ZIP
Total won ___________________ Illinois Income Tax withheld ____________
2 __ __ __ __ __ __ __ __ __
______________
Write the Social Security number (SSN) or federal employer identification
number (FEIN), name, and address of the person to whom winnings were
Taxpayer identification number (SSN or FEIN)
Amount won
made payable.
________________________________________
Name
__ __ __ __ __ __ __ __ __
________________________________________
Taxpayer identification number (SSN or FEIN)
Street address
_______________________________________________________
________________________________________
Name
City
State
ZIP
_______________________________________________________
3 __ __ __ __ __ __ __ __ __
______________
Street address
Taxpayer identification number (SSN or FEIN)
Amount won
_______________________________________________________
________________________________________
City
State
ZIP
Under penalties of perjury, I declare that to the best of my knowledge and belief the names,
Name
addresses, and taxpayer identifying numbers which I have furnished correctly identify me as
________________________________________
the recipient of this payment and correctly identify each person entitled to any portion of this
payment.
Street address
_______________________________________________________
Signature
Date
________________________________________
Note: Give your completed and signed form to the person who pays you the winnings.
City
State
ZIP
This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required.
IL-5754 (R-12/05)
Failure to provide information may result in this form not being processed and may result in a penalty.
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