Form  5754                  Statement by Person(s) Receiving Gambling Winnings
 (Rev. December 2008)        © Recipients of gambling winnings should see the instructions on the back of this form. OMB No. 1545-0239
 Department of the Treasury  ©  Payers of gambling winnings should see the separate Instructions for Forms W-2G      Return to payer. Do not
Internal Revenue Service                                      and 5754.                                                   send to the IRS.
                                                                                                                           
             Date won                     Type of winnings             Game number                Machine number           Race number
                                                                                                                            
 Part I      Person to Whom Winnings Are Paid
              
                           Name                                                                  Address
                                                                                                  
 Taxpayer identification number                             Other I.D.                               Amount received  Federal income tax
                                                                                                                            withheld
                                                                                                                             
 Part II     Persons to Whom Winnings Are Taxable (continued on page 2)
                                                              
             (a) Name                  (b) Taxpayer                    (c) Address                   (d) Amount won  (e) Winnings from
                                identification number                                                                identical wagers
                                                                                                                      
Under penalties of perjury, I declare that, to the best of my knowledge and belief, the names, addresses, and taxpayer identification numbers that I have furnished correctly
identify me as the recipient of this payment and correctly identify each person entitled to any part of this payment and any payments from identical wagers.
 
 Signature ©                                                                       Date ©
                                                                                                                                                             
For Paperwork Reduction Act Notice, see back of form.                      Cat. No. 12100R                           Form 5754                              (Rev. 12-2008)

Form 5754 (Rev. 12-2008)                                                                                             Page 2
 Part II Persons to Whom Winnings Are Taxable (continued from page 1)                                                      
  
         (a) Name              (b) Taxpayer                  (c) Address             (d) Amount won      (e) Winnings from
                              identification number                                                      identical wagers
                                                                                                          
Instructions for Recipient of Gambling                       Paperwork Reduction Act Notice. We ask for the
                                                             information on this form to carry out the Internal Revenue
Winnings                                                     laws of the United States. You are required to give us the
Purpose  of form. You must complete Form 5754 if you         information. We need it to ensure that you are complying
receive gambling winnings either for someone else or as      with these laws and to allow us to figure and collect the
a member of a group of two or more people sharing the        right amount of tax. Regulations section 31.3402(q)
winnings, such as by sharing the same winning ticket.        requires you to furnish an information return to the payer
The information you provide on the form enables the          if you receive gambling winnings either for someone else
payer of the winnings to prepare Form W-2G, Certain          or as a member of a group of two or more people sharing
Gambling Winnings, for each winner to show the winnings      the winnings, such as by sharing the same winning ticket.
taxable to each.                                                 You are not required to provide the information
 Completing the form. If you are the person to whom          requested on a form that is subject to the Paperwork
gambling winnings are paid, enter your name, address,        Reduction Act unless the form displays a valid OMB
and taxpayer identification number in Part I. If the         control number. Books or records relating to a form or its
winnings are from state-conducted lotteries, the box         instructions must be retained as long as their contents
labeled “Other I.D.” may be left blank. The total amount     may become material in the administration of any Internal
received and the total federal income tax withheld must      Revenue law. Generally, tax returns and return
be entered in the remaining columns.                         information are confidential, as required by section 6103.
 Complete Part II to identify each winner and each               The time needed to complete this form will vary
winner’s share of the winnings. If you are also one of the   depending on individual circumstances. The estimated
winners, enter your information first in Part II by entering average time is 12 minutes.
“Same as above” in columns (a), (b), and (c) and the             If you have comments concerning the accuracy of this
applicable amounts in columns (d) and (e). Then complete     time estimate or suggestions for making this form
columns (a) through (e) for each of the other winners.       simpler, we would be happy to hear from you. You can
Return the form to the payer.                                write to the Internal Revenue Service, Tax Products
 Taxpayer identification number. The taxpayer                Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
identification number for an individual is the social        Constitution Avenue, NW, IR-6526, Washington, DC
security number or individual taxpayer identification        20224. Do not send this form to this address. Instead,
number. For all others, it is the employer identification    return it to the payer.
number.                                                       
 Signature. If federal income tax is withheld, the person
who receives the winnings must sign and date the form. If
no federal income tax is withheld, no signature is
required.
 
                                                                                                    Form 5754  (Rev. 12-2008)