Form 11-C

(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)
to June 30,
(Year)
OMB No. 1545-0123
Type
or
Print
Name Employer identification number
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
Business address (if different from your home address or address entered above)
Alias, style, or trade name, if any
For IRS Use Only
T $ 1
FF 2
FP 3
I 4
T $ 5 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: Principal Agent accepting wagers for another (see instructions)
Part II Additional Information (for principal only)
4 If the taxpayer is a firm, partnership, or corporation, give the true name of each member or officer.
True name Title Home address Social security number
5 Are you or will you be engaged in the business of accepting wagers on your own account? . . . . . Yes No
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) 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 Address Employer identification number
For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 16166V Form 11-C (Rev. 12-2013)
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Form 11-C (Rev. 12-2013) Page 2
Part III Additional Information (for agents accepting wagers on behalf of others)
6 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. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any
knowledge.

Signature of officer Date

Title
Paid
Preparer
Use Only
Print/Type preparers name Preparer's signature Date
Check if
self-employed
PTIN
Firms name

Firm's address

Firm's EIN

Phone no.
Form 11-C (Rev. 12-2013)
Form 11-C (Rev. 12-2013) Page 3
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 principals 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, 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).
Form 11-C (Rev. 12-2013) Page 4
Line 1. Enter the day and month that you will start
accepting wagers. A full months 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
$500
tax
$50
tax
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.
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.

F
o
r
m

11-C(V)
(Rev. December 2013)
Department of the Treasury
Internal Revenue Service
Payment Voucher

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

OMB No. 1545-0123
1 Enter your employer identification
number.
2
Enter the amount of your payment.

Make your check or money order payable to United States Treasury
Dollars Cents
3 Enter year and month as shown on Form 11-C.
Y Y Y Y M M
Send Form 11-C, this voucher, and payment to:
Department of the Treasury
Internal Revenue Service
Cincinnati, OH 45999-0101
4 Enter your business name (individual name if sole proprietor).
Enter your address.
Enter your city or town, state or province, country, and ZIP or foreign postal code.
Form 11-C (Rev. 12-2013) Page 6
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.
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.