Form 13797
(November 2006)
OMB No. 1545-2026
Department of the Treasury — Internal Revenue Service
Compliance Check Report
This page to be completed by the IRS ITG Specialist.
Use this form to fully document the activity and findings from your Compliance Check. This template
is designed to report on data for one entity within the tribe (each Employer Identification Number
(EIN) is considered to be one Entity for this purpose). If you decide to expand to additional tribal
entities, pages 2-7 should be completed for each entity and attached to the final report. Only one
summary sheet should be completed.
If you have any questions regarding a federal tax administration issue during the course of your Compliance
Check, or any questions regarding the completion of this form, please check our web resources, or contact:
Once the Compliance Check is completed, this document should be saved and returned on a 3½''
diskette or CD-Rom to:
In order to assist you in completing the Compliance Check, our records currently indicate the
following information in regard to this entity:
EIN:
Entity Name:
Address:
Required to file the following federal tax returns:
Form 940
Employer’s Annual Federal Unemployment (FUTA) Tax Return
Form 941
Employer’s Quarterly Federal Tax Return
Form 943
Employer’s Annual Return – Agricultural Employees
Form 945
Annual Return of Withheld Federal Income Tax
Form 990
Return of Exempt Organization
Form 1065
Partnership Tax Return
Form 1120
Corporation Income Tax Return
Form 720
Quarterly Federal Excise Tax Return
Form 730 Monthly Tax on Wagering
Form 11-C
Occupational Tax and Registration Return for Wagering
Form 1042 Ann. Withholding Return for U.S. Source Income of Foreign Persons
Form 2290
Highway Use Tax Return
Form 1041
Fiduciary Tax Return
Other
Catalog Number 48503Y
www.irs.gov
Form 13797 (11-2006)
Page 2 of 8
Tribal Entity Reviewed
Employer Identification Number (EIN)
Name of Entity
Address City State Zip
Activity of Entity Year Entity Started
Performs Services for the Tribe in the Area of
Which of the following tax issues are applicable to the entity:
YES
NO Tax Issues Present
Employment Tax (Withholding and FICA)
Information Reporting (Forms 1099)
Tip Income (do employees of the entity receive tip income)
Title 31 (Bank Secrecy Act compliance)
Natural Resources (Fishing and Land based income exclusions)
Excise Tax (Wagering)
Excise Tax (Other)
Employee Plans (pension and 401k plans) (are employees of the entity covered by an employee
retirement or income deferral plan)
Exempt Organizations (is the entity structured as a not-for-profit organization under Section 501
of the Internal Revenue Code)
Tax Exempt Bonds (does the entity have any outstanding obligations for tax exempt bonds issued)
Is the Entity presently required to file:
YES NO Form Form Description
Form 940
Employer’s Annual Federal Unemployment (FUTA) Tax Return
Form 941
Employer’s Quarterly Federal Tax Return
Form 943
Employer’s Annual Return – Agricultural Employees
Form 945
Annual Return of Withheld Federal Income Tax
Form 990
Return of Exempt Organization
Form 1065
Partnership Tax Return
Form 1120
Corporation Income Tax Return
Form 720
Quarterly Federal Excise Tax Return
Form 730
Monthly Tax on Wagering
Form 11-C
Occupational Tax and Registration Return for Wagering
Form 1042
Annual Withholding Return for U.S. Source Income of Foreign Persons
Form 2290
Highway Use Tax Return
Form 1041
Fiduciary Tax Return
Form W-2
Wage and Tax Statement
Form W-2G
Certain Gambling Winnings
Form 8027
Employer’s Annual Return of Tip Income and Allocated Tips
Form 1098-T
Tuition Statement
Form 1099-MISC Statement for Recipients of Miscellaneous Income
Form 1099-R
Distributions from Retirement, Insurance, or Profit Sharing Plans
Form 8300
Cash Transactions Over $10,000 Received in a Trade or Business
FinCEN Form 102
Suspicious Activity Report by Casinos and Card Clubs
FinCEN Form 103
Currency Transaction Report by Casinos
Catalog Number 48503Y www.irs.gov
Form 13797 (11-2006)
Page 3 of 8
Review of Forms
Comment from your reviews of copies of the most recently filed tax forms. Include comments on whether the returns were
accurately prepared; whether there were any returns processing problems, whether there was a balance due, whether
there were any penalties imposed, etc.
If problems were encountered, how could they have been mitigated?
Forms W-4
Does the entity have employees?
Yes No
Are Forms W-4 on file for every employee?
Yes No
Are all forms W-4 secured prior to initial payment?
Yes
No
If No, what percentage was received after initial payment?
Are all forms W-4 properly completed? Yes
No
If No, what percentage was incomplete?
Are new forms W-4 secured each year on all individuals
claiming to be exempt from income tax withholding?
No
Yes
List any other comments from inspection of Forms W-4.
Forms W-9
Does the entity make payments to vendors or independent contractors?
Yes No
Are Forms W-9 on file for every vendor or independent contractor?
Yes No
Are all forms W-9 secured prior to initial payment?
Yes No
If No, what percentage was received after initial payment?
Are all forms W-9 properly completed? Yes No
If No, what percentage was incomplete?
List any other comments from inspection of Forms W-9.
Catalog Number 48503Y www.irs.gov
Form 13797 (11-2006)
Page 4 of 8
Forms 1099
Are Forms 1099 filed for payments to all vendors and independent contractors for payments
in excess of $600 per year?
Yes
No
Is federal income tax withheld when required, due to invalid or missing Forms W-9?
Yes No
Employment Taxes
Do Forms W-3, W-2 and 941 reconcile for the most recent calendar year?
Yes
No
If No, comment on the discrepancy and any actions needed or taken to resolve it.
Were there Federal Tax Deposit penalties assessed that could have been avoided? Yes No
Does the entity provide any fringe benefits (i.e., medical insurance, life insurance,
tribal/employer-provided vehicle, tribal/employer-provided housing, etc.)
Yes
No
If Yes, list the type and whether they are deemed taxable in whole or part by the Entity.
Were taxable fringe benefits included on Forms W-2 for the applicable employee? Yes No
Does the entity pay Tribal Council members for their services on the Council (i.e. salary, meetings
fees, stipends, etc.)?
Yes No
Are the payments reported on Form W-2 or Form 1099? Yes
No
If reported on Form W-2, are there withholding for FICA, Medicare, and Federal Income Tax? Yes
No
Is the entity aware of Revenue Ruling 59-354?
Yes No
Are internal controls present to ensure that a Form 1099 is not issued to an employee for an item
that should be reported on Form W-2 (i.e. bonuses, excess reimbursement of expenses, personal
use of a tribal asset, etc.)?
Yes
No
Is the level of tax filings consistent with the activity of the entity (i.e. Do the wages paid and withholding
remittances appear accurate based on the size of the entity and the number of employees)?
Yes No
If No, comment on the discrepancy and any actions taken to resolve it.
Does the Entity utilize a payroll service or Employee Leasing entity to file any required employment
tax forms?
Yes No
If Yes, list the name, address and EIN of the service provider as well as the specific forms filed on behalf of the entity.
EIN
Name
Address City State Zip
Forms filed by payroll service on behalf of THIS entity
Is the entity required to file Form 940 (Employer’s Annual Federal Unemployment (FUTA) Tax Return?
Yes
No
If Yes, does the entity participate in the State Unemployment Tax Act (SUTA) program? Yes No
If yes, are you aware of the relief from Federal Unemployment Tax
that is available if you are in compliance with SUTA? Yes No
Catalog Number 48503Y www.irs.gov
Form 13797 (11-2006)
Page 5 of 8
Comment on tax compliance in the following areas, including if the area is “not applicable” since the Entity has
no involvement with the listed issue.
1.
General Welfare Programs
Is the Entity involved in the development and/or implementation of any programs that are designed
to promote the general welfare of tribal members?
Yes
No
If Yes, describe the nature of the programs and how the potential tax consequence of such program was
determined.
2. Employee Leasing
Is the Entity involved in leasing employees TO or FROM another entity?
Yes
No
Lease TO another entity Lease FROM another entity
Is the other entity controlled by the tribe or another tribe?
Yes No
Have all federal tax filings and payments been properly made?
Yes No
List any other comments on employee leasing.
3.
Excise Taxes
Comment on the excise taxes that are applicable to the Entity as reflected on Forms 720, 730, 2290, and 11-C
(include a comment on whether the essential government services exclusion was appropriately defined and applied
to any communication or fuel taxes)
4.
Non-Gaming Distributions to Members
Are there any distributions of non-gaming revenue made by the entity to any individuals (i.e. royalty
income, business profits, land claim proceeds, etc.)?
Yes No
If Yes, are Forms 1099 issued?
Yes No
If No (Forms 1099 are NOT issued) comment on the reason.
List any other comments on Non-Gaming Distributions.
Catalog Number 48503Y www.irs.gov
Form 13797 (11-2006)
Page 6 of 8
5. Housing Assistance for Law Enforcement Personnel Living in High Crime Tribal Areas
Does the Entity provide any tax-free housing for law enforcement officials to reside in areas
deemed to be a “high crime zone” by the Tribe?
Yes
No
If Yes, has the tribal governing body duly designated the zone and payments?
Yes No
List any other comments on law enforcement housing.
6.
Tip Income
Does the Entity have employees who receive tip income? Yes No
If Yes, is there a voluntary Tip Agreement in place (Tip Rate Determination Agreement or a
Gaming Industry Tip Compliance Agreement? Yes No
What is the percentage of tipped employees who are participating in such an agreement?
If there are non-participating employees, do all of them report their tip income to the entity
as required each month? Yes No
Are all employee tips properly reported on line 6c of Form 941?
Yes
No
Comment on whether the tip income being reported by employees appears accurate.
7.
Bank Secrecy Act (BSA) Issues
Is the Entity subject to Title 31 (gross gaming revenues of $1 million or more per year,
or the entity provides services such as check cashing, wire transfers, etc.)? Yes No
Does the entity have a designated BSA Compliance Officer?
Yes No
Is that position solely dedicated to that task? Yes No
Does the entity have formal written BSA compliance program?
Yes No
Is ongoing Bank Secrecy Act training held for all employees who interact with customers
on the gaming floor, or work in security? Yes No
Comment on the level of filings of FinCEN Forms 102 and 103, specifically whether the number
being filed is changing in proportion to any changes in the size of the gaming operation.
8.
Per Capita Distributions of Gaming Revenues to Members
Does the Tribe distribute any gaming revenues directly to tribal members?
Yes No
Does the Tribe have a Revenue Allocation Plan (RAP)? Yes
No
If Yes, is the tribe in compliance with it’s RAP?
Yes No
Is Form 1099 issued to each recipient?
Yes No
Is proper withholding made from the distributions?
Yes No
List any other comments on Per Capita Gaming Distributions
Catalog Number 48503Y www.irs.gov
Form 13797 (11-2006)
Page 7 of 8
9. Use of Trusts or Other Programs to Defer Distributions, or the Tax Consequence of Distributions
Are any programs utilized by the tribe or tribal members to defer the tax consequence of a distribution, or
to defer the actual distribution to a later date (i.e. through the use of a trust or other legal structure)? Yes
No
Are they operated by the tribe? Yes No
Are they under contract or facilitated by a third party?
Yes No
Were the guidelines in Revenue Procedure 2003-14 used? Yes No
If not, was a Private Letter Ruling secured on the deferral program? Yes No
List any other comments on use of Trusts.
10. Aggregation Agreement on Gaming
Does the Entity have an agreement with the IRS to aggregate slot machine wins for a patron in a
gaming day? Yes
No
If Yes, is the entity in compliance with that agreement? Yes No
List any other comments on aggregation agreements.
11. Acceptance Agent Agreement on ITINs for Gaming Patrons
Does the Entity have an agreement with the IRS to secure Tax Identification Numbers for gaming
patrons from foreign countries who lack a social security number?
Yes No
If Yes, is the entity in compliance with that agreement? Yes No
List any other comments on ITIN agreements.
Actions / Corrections / Improvements
List any actions that the Tribe has taken on its own, or plans to implement, to effect improvements in compliance as a
result of conducting this Compliance Check.
List any actions where the IRS office of Indian Tribal Governments could assist the Tribe in effecting improvements to
compliance (i.e. Outreach/Education, improved access to information, need for a Private Letter Ruling, implementation of
a Tip Agreement, etc.) Note: Specific identified compliance concerns that may result in additional tax or penalties can be
listed at the conclusion of this form if you are seeking IRS assistance and potential penalty relief.
Catalog Number 48503Y www.irs.gov
Form 13797 (11-2006)
Page 8 of 8
SUMMARY OF COMPLIANCE CHECK
Name of Tribe
Address of Tribe City
State
Zip
Date Compliance Check Completed
Tribal Entity Contact Name
Tribal Entity Contact Title
Tribal Entity Contact Telephone Number Tribal Entity Contact E-Mail Address
The following information summarizes the results of the Compliance Check that was conducted
(complete all applicable sections)
EMPLOYER IDENTIFICATION NUMBER (EIN) CHANGES REQUIRED
(List the affected EINs, check the column for the change(s) required
and list an explanation for each change in the last column).
EIN
New
EIN
Change
of
Address
Filing
Requirement
Change
Other Explanation of Change
REQUIRED CORRECTIVE ACTIONS UNCOVERED BY COMPLIANCE CHECK
Based on the results of this Compliance Check, we request assistance in effecting the following corrective actions with the
understanding that penalties will be waived wherever permissible.
Privacy Act Statement and Paperwork Reduction Act Notice
This notice is given under the Privacy Act of 1974 and the Paperwork Reduction Act of 1995. The Privacy Act and Paperwork Reduction Act requires
that the Internal Revenue Service inform businesses and other entities the following when asking for information.
The information on this form will carry out the Internal Revenue laws of the United States. We will comply with Internal Revenue Code (IRC) section
6109 and the regulations hereunder, which generally require the inclusion of an Employer Identification Number (EIN) on certain returns, statements, or
other documents filed with the Internal Revenue Service. Information on this form may be used to determine which Federal tax returns are required to
file and to provide related forms and publications. This Form will be disclosed to the Social Security Administration for their use in determining
compliance with applicable laws. An EIN will not be issued unless you provide all of the requested information, which applies to your entity.
Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a valid OMB control number. Books or records relating to a form or its instructions must be retained as long
as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential,
as required by IRC section 6103.
Catalog Number 48503Y www.irs.gov
Form 13797 (11-2006)
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