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Get Form 5754 (Rev. September 1997). Statement By Person(s) Receiving Gambling Winnings

Ry Internal Revenue Service Date won Part I Payers of gambling winnings should see the separate Instructions for Forms 1099, 1098, 5498, and W-2G. Type of winnings Game number OMB No. 1545-0239 Return to payer. Do not send to the IRS. Machine number Race number Person to Whom Winnings Are Paid Name Address Taxpayer identification number Part II Other I.D. Amount received Federal income tax withheld Persons to Whom Winnings Are Taxable (continued on page 2) (a) Name (b) Taxpayer id.

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