Pennsylvania Personal Income Tax Verification of Gambling and Lottery Losses Affidavit

Personal Income Tax Verification of Gambling and Lottery Losses Affidavit
Personal Income Tax Verification of Gambling and Lottery Losses Affidavit (REV-1875)
(EX) MOD 08-20

REV-1875
SECTION I

PERSONAL INCOME TAX
VERIFICATION OF GAMBLING AND
LOTTERY LOSSES AFFIDAVIT

GENERAL INFORMATION
Tax Year

Name

SSN

Primary Taxpayer Name (Shown on the PA-40)

Primary Taxpayer SSN (Shown First on the PA-40)

Gambling and Lottery Winnings

SECTION II

Gambling and Lottery Losses

AFFIDAVIT

I hereby verify upon oath/affirmation that I am the person named above and have incurred the gambling and/or lottery losses indicated on this form for the
tax year shown above.
Signature

Date

Please notarize in the space below.

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REV-1875 (EX) MOD 08-20

SECTION III

SUMMARY SHEET

DATE: List the date of your gambling activity.
TYPE: List the type of gambling activity (lottery, raffle, horse racing, casino, etc.)
NAME AND ADDRESS: List the name and address or location of the gambling establishment.
AMOUNT: Provide the amount(s) you lost.
DATE

TYPE

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Instructions for REV-1875

REV-1875 IN (EX) MOD 08-20

Personal Income Tax Verification of Gambling and Lottery Losses Affidavit

GENERAL INFORMATION

SECTION III

You must be able to prove gambling losses used to offset
winnings reported on PA Schedule T. Proof of losses may
take several forms, including providing copies of losing
tickets, a daily log or a journal of wins and losses. Form REV1875 is to be used in the event that you are unable to submit
documentation to support all of your losses.

SUMMARY SHEET
To expedite the processing of your income tax return,
provide a detailed listing of your winnings and losses and
photocopies of any tickets, bets, and other wagering that you
have with the submission of your affidavit.

LINE INSTRUCTIONS

NOTE: Please do not send your originals to the
department as they will not be returned and should be
retained for your records.

SECTION I

HOW TO FILE

GENERAL INFORMATION
NAME/SSN/TAX YEAR
Provide the required information for the taxpayer claiming
the costs for tickets, bets and other wagering.
PRIMARY TAXPAYER NAME/PRIMARY TAXPAYER SSN
Provide the required information for the primary taxpayer
listed on the PA-40.

SECTION II
AFFIDAVIT
After completing the form, sign the form under oath/affirmation before a licensed Notary Public as verification of the
statements and information provided on the form.

OPTIONS FOR PROVIDING THE INFORMATION
You may email, fax or mail the form and documentation to
the department. When emailing or faxing the form and
documentation, use a DEX-93, Personal Income Tax
Correspondence Sheet.
Email the information to RA-BITPITFIELDREFAXE@
PA.GOV or fax it to 717-346-0649. When mailing the form
and documentation, mail it to the department at:
PENNSYLVANIA DEPARTMENT OF REVENUE
PO BOX 280600
HARRISBURG PA 17128-0600
NOTE: Emailing or faxing the form and documentation
to the department will reduce the processing time of
your return.

www.revenue.pa.gov
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