Form 11-C - Occupational Tax And Registration Return For Wagering Page 5

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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, 2012, enter 201207.
your payment more promptly and accurately, and to
improve our service to you.
Box 4. Enter your name and address as shown on Form
11-C.
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 do not have an EIN, apply for one online.
order. Do not send cash. Do not staple Form 11-C(V) or
Go to the IRS website at
your payment to Form 11-C (or to each other).
and click on the “Employer ID Numbers” link. You may
• Detach Form 11-C(V) and send it with your payment
also apply for an EIN by calling 1-800-829-4933, or you
and Form 11-C. See Where to file on page 3.
can fax or mail Form SS-4, Application for Employer
Identification Number, to the IRS.
Detach Here and Mail With Your Payment and Form 11-C.
▼
▼
11-C(V)
Payment Voucher
OMB No. 1545-0123
(Rev. December 2013)
Department of the Treasury
Do not staple or attach this voucher to your payment or Form 11-C.
▶
Internal Revenue Service
1 Enter your employer identification
Dollars
Cents
2
Enter the amount of your payment.
▶
number.
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).
Y
Y
Y
Y
M
M
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
Cincinnati, OH 45999-0101

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