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 is important tax
information and is
being
WINNER’S name
11 First I.D.
12 Second I.D.
furnished to the
Internal
Revenue Service. If
you are required to
file a return, a
Street address (including apt. no.)
13 State/Payer’s state identification no. 14 State winnings
negligence penalty or
other sanction may
be imposed on you if
$
this income is taxable
and the IRS
City or town, province or state, country, and ZIP or foreign postal code
15 State income tax withheld
16 Local winnings
determines that
it has not been
reported.
$
$
17 Local income tax withheld
18 Name of locality
Copy C
For Winner's Records
$
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