Certificate
(In support of credit or refund with respect to laid-off wagers under section 6419(b) of the Internal Revenue Code.)
I hereby certify that I, or the __________ (Corporation, partnership, or syndicate) of which I am an officer or member, doing business at ________________________, (Address) registered with the District Director of Internal Revenue at ____________________, ____________________ under Registration No. ________ as a person accepting wagers within the meaning of section 4401 of the Internal Revenue Code, accepted laid-off wagers, in the amounts and on the dates indicated below, from __________________, (Name) ________________, (Address) during the month of ________________, 19____.
Date | Amount of laid-off wager | Subject of laid-off wager (Identify horse and track, particular contest, or contestant, etc.) |
(Attach supplemental sheets for additional entries, if necessary.)
The undersigned further certifies that he, or the corporation, partnership, or syndicate of which he is a member will make return of and account for the tax, under section 4401 of the Internal Revenue Code, with respect to the laid-off wagers so accepted.
It is understood by the undersigned that this certificate is given for the purpose of enabling the person from whom the laid-off wagers were accepted to claim credit with respect to the tax due on such laid-off wagers or to claim credit or refund of the tax, if any, paid on such laid-off wagers.
It is further understood that the fraudulent use of this certificate will subject the undersigned and all guilty parties to a fine of not more than $10,000 or to imprisonment for not more than five years, or both, together with costs of prosecution.
(Signed) _______________________________
(Date) _______________________________
(Title) _______________________________
(Owner, President Partner, Member, etc.)
26 C.F.R. §44.6419-2