Form 11-C - Occupational Tax And Registration Return For Wagering Page 2

Download a blank fillable Form 11-C - Occupational Tax And Registration Return For Wagering in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 11-C - Occupational Tax And Registration Return For Wagering with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Form 11-C (Rev. 12-2017)

Page

Part III

Additional Information (for agents accepting wagers on behalf of others)

If you receive or will be receiving wagers on behalf of, or as an agent for, some other person or persons, give the true name,

address, and employer identification number of each person.

True name

Address

Employer identification number

Part IV

Supplemental Registration (see instructions)

Explain why you’re filing a supplemental registration. Include the date of the event.

Under penalties of perjury, I declare that I’ve examined this return and/or registration (including any accompanying statements or lists), and to the best of my

knowledge and belief, it’s true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any

Sign

knowledge.

Here

Signature of officer

Date

Title

Print/Type preparer’s name

Preparer’s signature

Date

PTIN

Paid

Check