(Rev. December 2013)

11-C

Form

(Rev. December 2013)

Department of the Treasury

Internal Revenue Service

Occupational Tax and Registration Return for Wagering

▶ Information about Form 11-C and its instructions is at www.irs.gov/form11c.

Return for period from

(Month and day)

(Year)

(Year)

Employer identification number

Name

Type

or

Print

Number, street, and room or suite no.

City or town, state or province, country, and ZIP or foreign postal code

Check one:

First return

Renewal return

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

Daytime telephone number

For IRS Use Only

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

T $

FF

FP

I

T $

Alias, style, or trade name, if any

Part I

Occupational Tax

1

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

.

.

2

Tax (see instructions) . . . . . . . . . . . . . . . . . . . . . .

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

.

.

3

Check one:

Part II

4

Principal

1

2

3

4

5

$

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

OMB No. 1545-0123

to June 30,

,

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 or town, state or province, country, and ZIP or foreign postal code

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

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

True name

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Address

Employer identification number

Cat. No. 16166V

Form 11-C (Rev. 12-2013)

Page 2

Form 11-C (Rev. 12-2013)

Part III

6

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

Part IV

7

Employer identification number

Supplemental Registration (see instructions)

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

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. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any

knowledge.

Signature of officer

Print/Type preparer’s name

Paid

Preparer

Use Only Firm’s name

▶

Firm's address ▶

Date

Preparer's signature

▲

▲

Sign

Here

Address

Title

Date

Check

if

self-employed

PTIN

Firm's EIN ▶

Phone no.

Form 11-C (Rev. 12-2013)

Page 3

Form 11-C (Rev. 12-2013)

Section references are to the Internal Revenue Code

unless otherwise noted.

Future Developments

For the latest information about developments related to

Form 11-C and its instructions, such as legislation

enacted after they were published, go to www.irs.gov/

form11c.

General Instructions

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 Line 2 on page 4 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 stateconducted 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, Monthly

Tax Return for Wagers, 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/small and click on

the “Employer ID Numbers” link. 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. Send Form 11-C, your check or money

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

Department of the Treasury

Internal Revenue Service

Cincinnati, OH 45999-0101

Send 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 about

private delivery services.

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.

If you receive a notice about penalty after you file this

return, reply to the notice with an explanation and we will

determine if you meet reasonable-cause criteria. Do not

attach an explanation when you file your return.

Disclosure of information on wagering taxes. Except

for administering or enforcing Internal Revenue taxes,

neither the Treasury Department nor any of its

employees may disclose documents, records, or

information obtained through them that a taxpayer

supplies in connection with wagering taxes. Also, certain

documents related to wagering taxes and information

obtained through them that relates to wagering taxes may

not be used against the taxpayer in any nontax criminal

proceeding. See section 4424 for more details.

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 (Form 8849), Other

Claims. See the Instructions for Form 8849 for details.

Specific Instructions

Return period. Enter the month, day, and year the return

period begins. Also, enter the ending year. Write the year

as a four-digit number (for example, 2013 or 2014).

Page 4

Form 11-C (Rev. 12-2013)

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

$500

$50

accepting

tax

tax

wagers in

July . . . . . . . $500.00 . . . . $50.00

August . . . . . . 458.33 . . . . 45.83

September . . . . 416.66 . . . . 41.66

October . . . . . 375.00 . . . . 37.50

November . . . . 333.33 . . . . 33.33

December . . . . 291.66 . . . . 29.16

January . . . . . 250.00 . . . . 25.00

February . . . . . 208.33 . . . . 20.83

March . . . . . . 166.66 . . . . 16.66

April . . . . . . . 125.00 . . . . 12.50

May . . . . . . .

83.33 . . . .

8.33

June . . . . . .

41.66 . . . .

4.16

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.

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. If you, as a principal, change your home or

business address, you must file a supplemental

registration before accepting wagers at the new address

or by the end of the 30-day period after the change,

whichever occurs first. If you engage a new agent to

receive wagers, you must file, within 10 days of engaging

the agent, a supplemental registration reporting the

agent's name, address, and EIN.

You must file a supplemental registration within 30

days of the occurrence of any of the following events.

• As the surviving spouse or child, executor,

administrator, or other legal representative, you continue

for the remainder of the period the business of a

deceased person who paid the occupational tax.

• As a receiver, trustee in bankruptcy, or assignee for

creditors, you continue the business for the remainder of

the period.

• There is a change of members of a partnership which is

a principal.

• There is a name change of a corporation which is a

principal.

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.

• Check the "supplemental registration" box.

• 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.

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/small

and click on the “Employer ID Numbers” link. 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

▼

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, 2012, enter 201207.

Box 4. Enter your name and address as shown on Form

11-C.

• Enclose your check or money order made payable to

“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 3.

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

11-C(V)

▼

Payment Voucher

(Rev. December 2013)

Department of the Treasury

Internal Revenue Service

OMB No. 1545-0123

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

1 Enter your employer identification

number.

2

Enter the amount of your payment. ▶

Dollars

Make your check or money order payable to “United States Treasury”

4

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

Y

Y

Y

Y

M

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

M

Enter your address.

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

Department of the Treasury

Internal Revenue Service

Cincinnati, OH 45999-0101

Enter your city or town, state or province, country, and ZIP or foreign postal code.

Cents

Form 11-C (Rev. 12-2013)

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 you owe and to register certain

information with the IRS. Section 6109 requires you to

provide your identification number. Unless specifically

prohibited by law, routine uses of this information include

giving it to the Department of Justice for civil and criminal

litigation; to cities, states, the District of Columbia, and

U.S. commonwealths and possessions for use in

administering their tax laws; to other countries under a

tax treaty; to federal and state agencies to enforce federal

nontax criminal laws; or to federal law enforcement and

intelligence agencies to combat terrorism. If you fail to

provide this information in a timely manner, you may be

subject to penalties.

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.

Page 6

The time needed to complete and file this form will

vary depending on individual circumstances. The

estimated average time is: Recordkeeping, 3 hrs., 49

min.; Learning about the law or the form, 57 min.;

Preparing the form, 2 hrs., 0 min.; and Copying,

assembling, and sending the form to the IRS, 16 min.

If you have suggestions for making this form simpler,

we would be happy to hear from you. You can send us

comments from www.irs.gov/formspubs/. Click on “More

Information” and then on “Comment on Tax Forms and

Publications.” Or you can send your comments to:

Internal Revenue Service

Tax Forms and Publications

SE:W:CAR:MP:TFP

1111 Constitution Ave. NW, IR-6526

Washington, DC 20224

Do not send the form to this address. Instead, see

Where to file, earlier.

We respond to many letters by telephone. Therefore, it

would be helpful if you would include your daytime phone

number, including the area code, in your correspondence.

Although we cannot respond individually to each

comment received, we do appreciate your feedback and

will consider your comments as we revise our tax

products.