Form 11-C - Occupational Tax And Registration Return For Wagering

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11-C
Occupational Tax and Registration Return for Wagering
Form
Go to for the latest information.
▶
OMB No. 1545-0236
(Rev. December 2017)
Return for period from
to June 30,
,
Department of the Treasury
(Month and day)
(Year)
(Year)
Internal Revenue Service
Employer identification number
Name
Type
Number, street, and room or suite no.
or
Print
City or town, state or province, country, and ZIP or foreign postal code
Check one:
First return
Renewal return
Daytime telephone number
Supplemental registration (Don’t complete lines 1, 2, 4, 5, or 6.)
Business address (if different from your home address or address entered above)
For IRS Use Only
T $
1
FF
2
FP
3
Alias, style, or trade name, if any
I
4
Part I
Occupational Tax
T $
5
1
Enter the date (month and day) you’ll start accepting wagers during the tax period .
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2
Tax (see instructions) .
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$
See the attached Form 11-C(V), Payment Voucher, for how to make your payments.
3
Check one:
Principal
Agent accepting wagers for another (see instructions)
Part II
Additional Information (for principal only)
4
If the taxpayer is a firm, partnership, or corporation, give the true name of each member or officer.
True name
Title
Home address
Social security number
5
Are you or will you be engaged in the business of accepting wagers on your own account? .
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Yes
No
If “Yes,” complete a, b, and c.
a Name and address where each business is or will be conducted:
Name of location
Address (number and street)
City or town, state or province, country, and ZIP or foreign postal code
b Number of agents engaged in receiving wagers on your behalf
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c True name, address, and employer identification number of each agent:
True name
Address
Employer identification number
11-C
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 12-2017)
Cat. No. 16166V

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