Illinois Statement by Person Receiving Gambling Winnings

Statement by Person Receiving Gambling Winnings
IL-5754, Statement by Person Receiving Gambling Winnings
	

	

Illinois Department of Revenue

IL-5754 Statement by Person Receiving Gambling Winnings

Who must complete this form?

You must complete Form IL-5754 if you receive payment of Illinois lottery
winnings of $1,000 or more; or gambling, pari-mutuel wagering, and sports
wagering winnings that are subject to federal withholding (more than $5,000).
This form provides a record of who received winnings and to whom the
winnings are taxable. The payer will use this information to prepare Form
W‑2G.

Step 2: Who will receive winnings? (Complete the following information
for each person receiving winnings.)

1	__ __ __ __ __ __ __ __ __	
	

What if I need additional assistance?

Taxpayer identification number (SSN or FEIN)	

______________

Amount won

________________________________________
Name

If you need assistance, visit our website at tax.illinois.gov; call our Taxpayer
Assistance Division at 1 800 732‑8866 or 217 782-3336; or call our TDD
(telecommunications device for the deaf) at 1 800 544-5304. Our office hours
are 8 a.m. to 5 p.m.

________________________________________

Step 1: Winnings information (Complete the following information.)

City	

Date of payment ____/____/____	 Type of winnings ____________________
Total won ___________________	Illinois Income Tax withheld ____________
Write the Social Security number (SSN) or federal employer identification
number (FEIN), name, and address of the person to whom winnings were
made payable.

Street address

________________________________________
2	__ __ __ __ __ __ __ __ __	
	

ZIP

______________

Amount won

________________________________________
Name

________________________________________

__ __ __ __ __ __ __ __ __

Street address

Taxpayer identification number (SSN or FEIN)

________________________________________

_______________________________________________________
Name

_______________________________________________________
Street address

_______________________________________________________
City	

Taxpayer identification number (SSN or FEIN)	

State	

State	

ZIP

Under penalties of perjury, I declare that to the best of my knowledge and belief the names,
addresses, and taxpayer identifying numbers which I have furnished correctly identify me as
the recipient of this payment and correctly identify each person entitled to any portion of this
payment.

_______________________________________________________
Signature						Date

City	

3	__ __ __ __ __ __ __ __ __	
	

Taxpayer identification number (SSN or FEIN)	

State	

ZIP

______________

Amount won

________________________________________
Name

________________________________________
Street address

________________________________________
City	

State	

ZIP

Step 3: Provide this completed and signed form to the person who is paying
the winnings.
IL-5754 (R-08/22)

This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required.
Failure to provide information may result in this form not being processed and may result in a penalty.