I.R.S. SPECIFICATIONS (2006)

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I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS

FORM 11-C, PAGE 1 of 4

PRINTS: HEAD TO HEAD

MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.

PAPER: WHITE WRITING, SUB. 20.

INK: BLACK

FLAT SIZE: 203mm (8")  279mm (11")

PERFORATE: (NONE)

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

11-C

Action

Date

Signature

O.K. to print

Revised proofs

requested

Occupational Tax and Registration Return for Wagering

Form

(Rev. April 2006)

OMB No. 1545-0236

Return for period from

Department of the Treasury

Internal Revenue Service

,

(Month and day)

to June 30,

(Year)

(Year)

Name

Employer identification number

Number, street, and room or suite no.

Type or print.

City, state, and ZIP code

Check one:

Daytime telephone number

First return

Renewal return

Supplemental registration (Do not complete lines 1, 2, 4, 5, and 6.)

(

)

Business address (if different from your home address or address entered above)

For IRS Use Only

Alias, style, or trade name, if any

Part I

Occupational Tax

1

2

Enter the date (month and day) you will start accepting wagers during the tax period

Tax (see instructions)

See Form 11-C(V), Payment Voucher, for how to make your payments.

3

Check one:

Part II

4

Principal

$

Agent accepting wagers for another (see instructions)

Additional Information (for principal only)

If the taxpayer is a firm, partnership, or corporation, give the true name of each member or officer.

True name

5

1

2

3

4

5

T $

FF

FP

I

T $

Title

Home address

Are you or will you be engaged in the business of accepting wagers on your own account?

If “Yes,” complete a, b, and c.

a Name and address where each business is or will be conducted:

Name of location

Address (number and street)

Social security number

Yes

No

City, state, and ZIP code

b Number of agents engaged in receiving wagers on your behalf 䊳

c True name, address, and employer identification number of each agent:

True name

Part III

6

Address

Employer identification number

Additional Information (for agents accepting wagers on behalf of others)

If you receive or will be receiving wagers on behalf of or as an agent for some other person or persons, give the true name,

address, and employer identification number of each person.

True name

Address

Employer identification number

Part IV Supplemental Registration (see instructions)

7

Explain why you are filing a supplemental registration. Include the date of the event.

Sign

Here

Under penalties of perjury, I declare that I have examined this return and/or registration (including any accompanying statements or lists), and, to

the best of my knowledge and belief, it is true, correct, and complete.

䊳

Signature

For Privacy Act and Paperwork Reduction Act Notice, see page 4.

Date

䊳

Title

Cat. No. 16166V

Form 11-C (Rev. 4-2006)

2

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS

FORM 11-C, PAGE 2 of 4

MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.

PRINTS: HEAD TO HEAD

PAPER: WHITE WRITING, SUB. 20.

INK: BLACK

FLAT SIZE: 203mm (8")  279mm (11")

PERFORATE: (NONE)

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page 2

Form 11-C (Rev. 4-2006)

General Instructions

Section references are to the Internal

Revenue Code unless otherwise noted.

Purpose of form. Form 11-C is used to

register certain information with the IRS and

to pay the occupational tax on wagering. You

must pay the occupational tax if you accept

taxable wagers for yourself or another person.

There are two amounts of occupational tax

($50 or $500). One or the other applies

depending on whether the wagers you accept

are authorized by the laws of the state in

which you accept the wager. See the

instructions for Line 2 to determine your

occupational tax. Your cancelled check is

proof of registration and payment.

Who must file. File Form 11-C if you are a

principal or an agent.

1. A principal is a person who is in the

business of accepting taxable wagers for his

or her own account. This is the person who

makes a profit or risks loss depending on the

outcome of the event or contest for which the

wager is accepted.

2. An agent is a person who accepts

taxable wagers on the principal’s behalf.

Taxable wagers include those placed:

● On a sports event or contest with a person

engaged in the business of accepting wagers

on a sports event or contest.

● In a wagering pool on a sports event or

contest if the pool is conducted for profit.

● In a lottery conducted for profit (other than

a state-conducted lottery). The term lottery

includes the numbers game, policy, punch

boards, and similar types of wagering.

What is not taxed. The tax is not imposed

on the following five items:

● A parimutuel wagering enterprise, including

horse racing, dog racing, and jai alai, when

licensed under the laws of the state in which

accepted.

● Coin-operated devices, such as pinball

machines.

● Sweepstakes, wagering pools, or lotteries

that are conducted by an agency of a state, if

the wager is placed with the state agency or

its authorized agents or employees.

● Games of the type in which usually all

persons placing wagers in the game are

present when wagers are placed, winners are

determined, and prizes or other property are

distributed.

● Drawings conducted by an organization

exempt from tax under sections 501 or 521,

as long as the net proceeds of the drawing

do not inure to the benefit of a private

shareholder or individual.

Definitions. See the Instructions for Form 730

for the definition of sports event, contest,

wagering pool, and lottery.

When to file. File the first return before

wagers are accepted. After that, file a renewal

return by July 1 for each year wagers are

accepted. A first return is also due in certain

situations in which there has been a change

in ownership or control. The return must be

filed within 30 days after new members are

admitted to a firm or partnership; a

corporation is formed to continue the

business of a partnership; or a stockholder

continues the business of a dissolved

corporation.

Employer Identification Number (EIN). Enter

your EIN. If you do not have an EIN, apply for

one online. Go to the IRS website at

www.irs.gov/businesses and click on the

“Employer ID Numbers” link under

“Businesses Topics.” You may also apply for

an EIN by calling 1-800-829-4933, or you can

fax or mail Form SS-4, Application for

Employer Identification Number, to the IRS.

Address. If you are an individual, enter your

home address.

Signature. Form 11-C must be signed by a

person who has authority to sign for the

taxpayer.

Where to file. Mail Form 11-C, your check or

money order, and Form 11-C(V) to:

Internal Revenue Service Center

Cincinnati, OH 45999-0101

Mail the return using the U.S. Postal

Service or other designated private delivery

service. See the instructions for your income

tax return for more information.

Penalties. There are penalties for not filing on

time, for accepting wagers before paying the

tax, and for willfully failing to file the return.

There are also penalties for making or helping

to make false returns, documents, or

statements.

Confidentiality of information. No Treasury

Department employee may disclose

information you supply in relation to wagering

tax except when needed to administer or

enforce the tax law. See section 4424 for

more information.

Refund. A refund for an overpayment of the

occupational tax may be claimed on Form

8849, Claim for Refund of Excise Taxes,

using Schedule 6. See the Instructions for

Form 8849 for details.

Specific Instructions

Return period. Enter the month, day, and

year that begins the return period. Also, enter

the ending year. Write the year as a 4-digit

number (for example, 2006 or 2007).

Line 1. Enter the day and month that you will

start accepting wagers. A full month’s tax is

due regardless of which day you start

accepting wagers during a month.

Line 2. Use the table below to determine the

tax. The $50 tax applies if all wagers

(including those accepted by an agent for

another) are authorized under the laws of the

state in which accepted. If you intend to

accept wagers that are not authorized by the

state, the $500 tax applies. The tax is payable

for the period that begins July 1 of each year.

If you start accepting wagers after July 31,

the tax is prorated for the first year.

Note. This tax is paid once for each period

that begins July 1. If you are required to file a

supplemental registration, do not pay the tax

a second time.

If you start

accepting

wagers in

July

August

September

October

November

December

January

$500

tax

$500.00

458.33

416.66

375.00

333.33

291.66

250.00

$50

tax

$50.00

45.83

41.66

37.50

33.33

29.16

25.00

February

208.33

20.83

March

166.66

16.66

125.00

12.50

April

May

83.33

8.33

41.66

4.16

June

Payment voucher. Complete Form 11-C(V),

Payment Voucher, and file it with Form 11-C

and your payment.

Line 3. You must check one of the boxes.

See Who must file for the definition of

principal and agent. Principals are liable for

the excise tax on wagers, which is reported

and filed monthly on Form 730, Monthly Tax

Return for Wagers.

Lines 4 and 5. These lines are to be

completed by principals only. Enter applicable

information for officers and/or partners of the

company on line 4. Enter on line 5a the name

and address of each location where business

will be conducted. Enter the number of

agents who accept wagers for you on line 5b

and their names, addresses, and EINs on

line 5c.

Line 6. This line is to be completed by agents

accepting wagers on behalf of another. Enter

the name, address, and EIN of each person

or company on whose behalf you accept

wagers.

Supplemental Registration

Line 7. A supplemental registration must be

filed by principals within 30 days (except for

items 1 and 7 below) when any of the

following events occur.

1. You change your business or home

address. You must register the change before

accepting wagers at the new address or by

the end of the 30-day period after the change

of address, whichever occurs first.

2. You continue for the remainder of the

period, as the surviving spouse or child,

executor, administrator, or other legal

representative, the business of a deceased

person who paid the occupational tax.

3. You continue for the remainder of the

period the business as a receiver or trustee in

bankruptcy.

4. You continue for the remainder of the

period the business as an assignee for

creditors.

5. One or more members withdraws from a

firm or partnership.

6. The corporate name is changed.

7. You engage a new agent to receive

wagers. You must file a supplemental

registration to report the name, address, and

EIN of each new agent within 10 days after

you engage the agent.

Agents. You must complete line 7 if you

have previously filed Form 11-C and are

engaged to receive wagers for another. You

must register the name, address, and EIN of

each new person who engaged you within 10

days after being engaged.

How to file a supplemental registration.

Complete the name, address, EIN, business

address, and alias lines. Also, be sure to

check the “supplemental registration” box.

Then check the applicable box on line 3 and

enter the information that has changed on

line 7, including the date of the event of

change. Do not complete lines 1, 2, 4, 5, or 6

for a supplemental registration.

Over-the-Counter

I.R.S. SPECIFICATIONS

2

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS

FORM 11-C, PAGE 3 of 4

MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.

PAPER: WHITE WRITING, SUB. 20.

TRIM SIZE: 216mm (81⁄2 ") x 279mm (11")

PERFORATE: 73⁄4 " from top

PRINTS: HEAD TO HEAD

INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 11-C(V),

Payment Voucher

Purpose of Form

Complete Form 11-C(V), Payment Voucher, and file it

with Form 11-C, Occupational Tax and Registration

Return for Wagering. We will use Form 11-C(V) to

credit your payment more promptly and accurately,

and to improve our service to you.

If you have your return prepared by a third party,

provide Form 11-C(V) to the return preparer.

Specific Instructions

Box 1. If you do not have an EIN, apply for one online.

Go to the IRS website at www.irs.gov/businesses and

click on the “Employer ID Numbers” link under

“Businesses Topics.” You may also apply for an EIN

by calling 1-800-829-4933, or you can fax or mail Form

SS-4, Application for Employer Identification Number,

to the IRS.

Form

䊲

Box 2. Enter the amount paid with Form 11-C.

Box 3. Enter the same year and month you entered on

the “Return for period from” line at the top of Form

11-C. For example, if your return is for the full period

that begins July 1, 2006, enter 200607.

Box 4. Enter your name and address as shown on

Form 11-C.

● Enclose your check or money order made payable to

the “United States Treasury.” Be sure to enter your

EIN, “Form 11-C,” and the tax period on your check or

money order. Do not send cash. Do not staple

Form 11-C(V) or your payment to Form 11-C (or to

each other).

● Detach Form 11-C(V) and send it with your payment

and Form 11-C. See Where to file on page 2.

Detach Here and Mail With Your Payment and Form 11-C.

11-C(V)

䊲

Payment Voucher

(Rev. April 2006)

OMB No. 1545-0235

Department of the Treasury

Internal Revenue Service

䊳 Do not staple or attach this voucher to your payment or Form 11-C.

1 Enter your employer identification

number.

3

Enter the amount of your payment. 䊳

4 Enter your business name (individual name if sole proprietor).

Enter year and month as shown on Form 11-C.

Y

Y

Y

Y

Dollars

2

M

M

Enter your address.

Send Form 11-C, this voucher, and payment to:

Internal Revenue Service

Cincinnati, OH 45999-0101

Enter your city, state, and ZIP code.

Cents

2

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS

FORM 11-C, PAGE 4 of 4

MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.

PRINTS: HEAD TO HEAD

PAPER: WHITE WRITING, SUB. 20.

INK: BLACK

FLAT SIZE: 203mm (8")  279mm (11")

PERFORATE: (NONE)

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page 4

Form 11-C (Rev. 4-2006)

Privacy Act and Paperwork Reduction Act

Notice. We ask for the information on Form

11-C to carry out the Internal Revenue laws

of the United States. You are required to give

us the information. We need it to ensure that

you are complying with these laws and to

allow us to figure and collect the right amount

of tax. Section 4411 imposes a special tax on

each person who is engaged in receiving

wagers for or on behalf of any person liable

for the tax on wagers. Section 4412 requires

that person to register with the IRS. Form

11-C is used to determine the amount of the

tax that you owe and to register certain

information with the IRS. Section 6109

requires you to provide your employer

identification number. Routine uses of this

information include giving

it to the Department of Justice for civil and

criminal litigation, and to cities, states, and

the District of Columbia for use in

administering their tax laws. If you fail to

provide this information in a timely manner,

you may be subject to penalties and interest.

You are not required to provide the

information requested on a form that is

subject to the Paperwork Reduction Act

unless the form displays a valid OMB control

number. Books or records relating to a form

or its instructions must be retained as long as

their contents may become material in the

administration of any Internal Revenue law.

Generally, tax returns and return information

are confidential, as required by section 6103.

The time needed to complete and file this

form will vary depending on individual

circumstances. The estimated average time

is: Recordkeeping, 7 hr. 24 min.; Learning

about the law or the form, 57 min.;

Preparing the form, 2 hr., 3 min.; and

Copying, assembling, and sending the form

to the IRS, 16 min.

If you have comments concerning the

accuracy of these time estimates or

suggestions for making this form simpler, we

would be happy to hear from you. You can

write to the Internal Revenue Service, Tax

Products Coordinating Committee,

SE:W:CAR:MP:T:T:SP, 1111 Constitution

Ave., NW, IR-6406, Washington, DC 20224.

Do not send the form to this address.

Instead, see Where to file on page 2.