CORRECTED (if checked)
OMB No. 1545-0238
PAYER’S name, street address, city or town, province or state, country, and
1 Reportable winnings
2 Date won
2017
ZIP or foreign postal code
$
Form W-2G
3 Type of wager
4 Federal income tax withheld
$
Certain
5 Transaction
6 Race
Gambling
Winnings
7 Winnings from identical wagers
8 Cashier
PAYER’S federal identification number
PAYER'S telephone number
$
9 Winner’s taxpayer identification no. 10 Window
This information
is being furnished
to the Internal
Revenue Service
WINNER’S name
11 First I.D.
12 Second I.D.
Copy B
Street address (including apt. no.)
13 State/Payer’s state identification no. 14 State winnings
Report this income
on your federal tax
$
return. If this form
City or town, province or state, country, and ZIP or foreign postal code
15 State income tax withheld
16 Local winnings
shows federal
income
$
$
tax withheld in
17 Local income tax withheld
18 Name of locality
box 4, attach this
copy to your return.
$
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.
Signature
Date
▶
▶
W-2G
Form
Department of the Treasury - Internal Revenue Service