14 State winnings CA $1,385.ġ5 State income tax withheld 16 Local winningsġ7 Local income tax withheld 18 Name of locality 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.
