Certain Gambling Winnings

• Issuer: Treasury Department
• Section: Treasury Department

Form W-2G

(Rev. December 2023)

Cat. No. 10138V

Certain

Gambling

Winnings

Department of the Treasury - Internal Revenue Service

Copy A

For Internal Revenue

Service Center

File with Form 1096

OMB No. 1545-0238

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

current General

Instructions for

Certain Information

Returns.

For calendar year

20

3232 VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country,

and ZIP or foreign postal code

PAYER’S TIN PAYER’S telephone no.

WINNER’S name

Street address (including apt. no.)

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

1 Reportable winnings

$

2 Date won

3 Type of wager 4

Federal income tax withheld

$

5 Transaction 6 Race

7

Winnings from identical wagers

$

8 Cashier

9 WINNER’S TIN 10 Window

11 First identification no. 12 Second identification no.

13

State/Payer’s state identification no.

14 State winnings

$

15 State income tax withheld

$

16 Local winnings

$

17 Local income tax withheld

$

18 Name of locality

Under penalties of perjury, I declare that, to the best of my knowledge and belief, the name, address, and taxpayer identification number that I have furnished

correctly identify me as the recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part of these payments.

Signature: Date:

Form W-2G (Rev. 12-2023) www.irs.gov/FormW2G

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