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b E

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loyer identification num

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c E

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loyer’s name, ad

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loyee’s first name and

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ithheld

7 S

ocial security tips

8 A

llocated tip

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9 V

erification code

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epend

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onqualified

plans

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ox 12Co d

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19 Local incom

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a E

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Visit the IR

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ebsite at

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b E

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loyer identification num

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c E

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loyer’s name, ad

dress, and

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loyee’s first name and

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ployee’s ad

dress and

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ages, tips, other compensation

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eral income tax w

ithheld

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ocial security wages

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ocial security tax withheld

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edicare w

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Form 1

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ur re

turn

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Dep

artment of the Treasury - Internal R

evenue Service

This information is

being furnished

to the Internal

Revenue S

ervice.

OM

B N

o. 1545-0119

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TED

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federal id

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entification num

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dress (includ

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mount allocab

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w

ithin 5 years

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requirem

ent

Account num

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1 G

ross distrib

ution

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Taxable am

ount

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Taxable am

ount not d

etermined

Total d

istribution

3 C

apital gain (includ

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4 Fed

eral income tax

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ithheld

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et unrealized

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istribution

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tate tax withheld

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13 S

tate/Payer’s state no.

14 S

tate distrib

ution

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ithheld

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ame of locality

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istribution

$$Form

1099-R

ww

w.irs.gov/form

1099r

Form 1

09

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Pa

ym

en

ts

Co

py B

Fo

r Re

cip

ien

t

Dep

artment of the Treasury - Internal R

evenue Service

This is imp

ortant tax inform

ation and is

being furnished

to the Internal R

evenue S

ervice. If you are req

uired to file a return,

a negligence penalty or

other sanction may b

e im

posed

on you if this incom

e is taxable and

the IR

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etermines that

it has not been

reported

.

OM

B N

o. 1545-0120

CO

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EC

TED

(if checked)

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R’S

name, street ad

dress, city or tow

n, state or province, country, Z

IP

or foreign postal cod

e, and telep

hone no.

RE

CIP

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T’S id

entification numb

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Account num

ber (see instructions)

1 U

nemploym

ent compensation

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tate or local income tax

refunds, cred

its, or offsets

$3 B

ox 2 amount is for tax year

4 Federal incom

e tax withheld

$5 R

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paym

ents

$6 Taxab

le grants

$7 A

griculture paym

ents

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, box 2 is

trade or b

usiness incom

e9 M

arket gain

$10a

State10b

State identification no.11 State incom

e tax withheld

$$Form

10

99

-G(keep

for your records)

ww

w.irs.gov/form

1099g

PA

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R’S

federal identification number

Fo

rm W

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in

Ga

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inn

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This information

is being furnished

to the Internal

Revenue S

ervice

Co

py B

Re

po

rt this

inc

om

e

on

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rm

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9D

epartm

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ervice

OM

B N

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OR

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D (if checked

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’S nam

e, street address, city or town, province or state, country, and

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PA

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R’S

federal identification number

PA

YE

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telephone num

ber

WIN

NE

R’S

name

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n, province or state, country, and

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e

1 R

eportab

le winnings

$

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ate won

3 Typ

e of wager

4 F

ed

era

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e ta

x w

ithh

eld

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6 R

ace

7 W

innings from identical w

agers

$

8 C

ashier

9 W

inner’s taxpayer identification no.10 W

indow

11 First I.D

.12 S

econd I.D

.

13

State/Payer’s state identification no.14 S

tate winnings

$15 S

tate income tax w

ithheld

$

16 Local w

innings

$17 Local incom

e tax withheld

$

18 N

ame of locality

Und

er penalties of p

erjury, I declare that, to the b

est of my know

ledge and

belief, the nam

e, add

ress, and taxp

ayer identification num

ber that I have furnished

correctly id

entify me as the recip

ient of this paym

ent and any p

ayments from

identical w

agers, and that no other p

erson is entitled to any p

art of these paym

ents.

Sig

na

ture

D

ate

Form W

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ww

w.irs.gov/w

2g

TWEN

TY-FOU

R SEVEN

456 MA

IN STREET

BIG RO

CK, IL 60511

24-700XXXX331-555-2477

PAU

L P. WA

TERS

Street ad

dress (includ

ing apt. no.)

240 MO

NRO

E

AU

RORA

, IL 60502

2,500.00 JU

LY 1, 2019

SLOTS

.00

475

567-00-XXXX

IL-2472472,500.00

0

BIG RO

CK

Form 1

098-T

2019

Tu

ition

S

tate

me

nt

Co

py B

Fo

r Stu

de

nt

Dep

artment of the Treasury - Internal R

evenue Service

This is imp

ortant tax inform

ation and

is being

furnished to the

IRS

. This form

must b

e used to

comp

lete Form 8863

to claim ed

ucation cred

its. Give it to the

tax prep

arer or use it to p

repare the tax return.

OM

B N

o. 1545-1574

CO

RR

EC

TED

FILER

'S nam

e, street add

ress, city or town, state or p

rovince, country, ZIP

or foreign p

ostal code, and

telephone num

ber

FILER

'S em

ployer id

entification no.S

TUD

EN

T'S TIN

STU

DE

NT'S

name

Street ad

dress (includ

ing apt. no.)

City or tow

n, state or province, country, and

ZIP

or foreign postal cod

e

Service P

rovider/A

cct. No. (see instr.)

8 C

heck if at least

half-time stud

ent

1 P

ayments received

for q

ualified tuition and

related

expenses

$23 If this b

ox is checked, your ed

ucational institution changed

its reporting m

ethod for 2018

4 A

djustm

ents mad

e for a p

rior year

$

5 S

cholarships or grants

$6 A

djustm

ents to scholarship

s or grants for a p

rior year

$

7 C

hecked if the amount

in box 1 includes am

ounts for an academ

ic period beginning January—

M

arch 2019

9 C

hecked if a grad

uate

student

10 Ins. contract reim

b./refund

$

Form 1

098-T

(keep for your record

s)w

ww

.irs.gov/Form1098T