Or state, country, and ZIP or foreign postal codeġ1 First identification 12 Second identification D5028075 606544592 JEFFREY H ANDERSON 124 JENNIFER LN VACAVILLE, CA 95687ġ3 State/Payer's state identification no.
WINNER'S name, street address (including apt. January 2021)ĩ Winner's taxpayer identification no. 1545- and ZIP or foreign postal code $1,385 12/02/ SHINGLE SPRINGS TRIBAL GAMING AUTHORITY Form W-2G RED HAWK CASINO 1 RED HAWK PARKWAY PLACERVILLE, CA 95667ģ Type of wager 4 Federal income tax withheld 7_SLOT_MACHINES Certain Gambling Winningsħ Winnings from identical wagers 8 Cashier PAYER'S federal identification number PAYER'S telephone number JUGUTIERREZ (Rev. SHINGLE SPRINGS TRIBAL GAMING AUTHORITY RED HAWK CASINO 1 RED HAWK PARKWAY PLACERVILLE, CA 95667 530-672- JEFFREY H ANDERSON 124 JENNIFER LN VACAVILLE, CA 95687ĬORRECTED (if checked) PAYER'S name, street address, city or town, province or state, country, 1 Reportable winnings 2 Date won OMB No.
