Form 5754 • Statement By Person(s) Receiving Gambling Winnings
For Winnings Between $600 - $5,000
Form must be filed within 30 days from date of receiving winnings. Send Completed for to: OHIO LOTTERY COMMISSION • 615 SUPERIOR AVE., N.W. CLEVELAND, OHIO 44113-9885 ATTENTION: RM 452 All recipients on this form will receive a W2G Form on or before January 31 of the following year $ GROSS WINNINGS DO NOT DEDUCT BANK FEE
PART I Primary Person Who Received Winnings – PLEASE PRINT OR TYPE
LOTTERY USE ONLY NUMBER OF WINNERS DATE WON LOTTERY GAME
SOCIAL SECURITY NO.
NAME (Last, First, Middle Initial)
COMPLETE MAILING ADDRESS (Street/PO, City, State, Zip)
Incomplete or illegible names, social security numbers, or addresses will not be processed. The primary recipient will be responsible for that share.
PART II Person to Whom Winnings Are Taxable
(a) NAME (Last, First, Middle Initial)
PLEASE PRINT OR TYPE
USE REVERSE SIDE FOR ADDITIONAL RECIPIENTS (c) COMPLETE MAILING ADDRESS (Street/PO, City, State, Zip) (d) $ AMOUNT OF WINNINGS RECEIVED
(b) SOCIAL SECURITY NUMBER
1. 2. 3. 4. 5. 6. 7. 8.
Under Penalties of perjury, I declare that, to the best of my knowledge and belief, the names, address, 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.
DATE SIGNATURE
DAYTIME PHONE
(d) NAME (Last, First, Middle Initial)
(e)
SOCIAL SECURITY NUMBER
(f)
COMPLETE MAILING ADDRESS (Street/PO, City, State, Zip)
(d) $ AMOUNT OF WINNINGS RECEIVED
9. 10. 11. 12. 13. 14. 15. 16.
• Instructions for Recipient of Gambling Winnings •
Paperwork Reduction Act Notice – We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to provide 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. The time needed to complete this form will vary depending on individual circumstances. The estimated average time is 12 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making this form more simple, we would be happy to here from you. You can write to both the Internal Revenue Service, Washington DC 20224, Attention IRS Reports Clearance Officer, T:FP; and the Office of Management and Budget, Paperwork Reduction Project (1545-0239), Washington DC 20503. DO NOT send this form to either of these offices. Instead, return it to the payer. Purpose of Form - You must complete Form 5754 if you receive gambling winnings either for someone else or as a member of a group of winners on the same winning ticket. The information you provide on the form enables the payer of the winnings to prepare Form W-2G, Certain Gambling Winnings, for each winner to show the winnings taxable to each. Completing the Form – If you are the person to whom gambling winnings are paid, enter your name, address, and taxpayer identification number in Part I. The total amount received must be entered in the appropriate column. Complete Part II to identify each winner and each winner’s share of the winnings. If you are also one of the winners, enter your information first in Part II by entering “Same as above” in columns (a), (b), and (c) and the applicable amount in column (d). Then complete columns (a) through (d) for each of the other winners. Return the form to the payer. Taxpayer Identification Numbers – The taxpayer identification number for an individual is the social security number; for all others, it is the employer identification 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. The person to whom the prize winnings were paid, shall be solely responsible for the entire prize amount and any tax consequences arising from 5754 forms which are rejected by the Lottery. Prizes greater than $5,000.00 are subject to federal and state withholding taxes. The Lottery is required to issue a W2G form to each person listed on 5754. The W2G forms will be mailed no later than January 31 of the year following the date on which the prize winnings were collected. A W2G will be issued to all persons sharing in a prize, regardless of distribution amount.
Ohio Lottery Commission • August 2004