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

13

OMB No. 1545-0238PAYER’s name, street address, city or town, province or 

tax withheld in box 4

CORRECTED (if checked)

1Gross winnings2

state, country, ZIP or foreign postal code

Federal income tax withheld

2013

Street Address3Type of wager4

Date won

Form W-2G

CertainCityStateZIP Code5Transaction6Race

Gambling

Winnings

Federal ID NumberTelephone Number

7Winnings from identical wagers8Cashier

WINNER’s name

9Winner’s taxpayer identification no.10Window

Street Address (including apt. no.)

11First I.D.12Second I.D.Copy B

Report this income on

CityStateZIP Code

State/Payer’s state identification no.14State winningsyour federal taxreturn. If this form

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

shows federal income

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.

attach this copy to

SignatureGDateG

your return.

Form W-2GDepartment of the Treasury - Internal Revenue Service

15  

$

16  

$

17  

$

18  

$

$

$

$

State income tax withheldLocal winnings

Local income tax withheldName of Locality

postal code

----------------Page (0) Break----------------