Form 11-C - Occupational Tax And Registration Return For Wagering Page 6

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Form 11-C(V),
Payment Voucher
Purpose of Form
Box 2. Enter the amount paid with Form 11-C.
Box 3. Enter the same year and month you entered on
Complete Form 11-C(V), Payment Voucher, and file it
the “Return for period from” line at the top of Form 11-C.
with Form 11-C, Occupational Tax and Registration
For example, if your return is for the full period that begins
Return for Wagering. We will use Form 11-C(V) to credit
July 1, 2017, enter 201707.
your payment more promptly and accurately, and to
improve our service to you.
Box 4. Enter your name and address as shown on Form
If you have your return prepared by a third party,
provide Form 11-C(V) to the return preparer.
• Enclose your check or money order made payable to
“United States Treasury.” Be sure to enter your EIN,
Specific Instructions
“Form 11-C,” and the tax period on your check or money
Box 1. If you don’t have an EIN, apply for one online. Go
order. Don’t send cash. Don’t staple Form 11-C(V) or your
to the IRS website at You also may
payment to Form 11-C (or to each other).
apply for an EIN by faxing or mailing Form SS-4,
• Detach Form 11-C(V) and send it with your payment
Application for Employer Identification Number, to the
and Form 11-C. See Where to file, earlier.
Detach Here and Mail With Your Payment and Form 11-C.
Payment Voucher
OMB No. 1545-0236
(Rev. December 2017)
Department of the Treasury
Don’t staple or attach this voucher to your payment or Form 11-C.
Internal Revenue Service
1 Enter your employer identification
Enter the amount of your payment.
Make your check or money order payable to “United States Treasury”
3 Enter year and month as shown on Form 11-C.
4 Enter your business name (individual name if sole proprietor).
Enter your address.
Send Form 11-C, this voucher, and payment to:
Department of the Treasury
Enter your city or town, state or province, country, and ZIP or foreign postal code.
Internal Revenue Service
Ogden, UT 84201-0101


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