Form Rev-1753 As Application For Small Games Of Chance Page 2

Download a blank fillable Form Rev-1753 As Application For Small Games Of Chance in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Rev-1753 As Application For Small Games Of Chance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

REV-1753 AS (03-16)

APPLICATION FOR SMALL GAMES OF CHANCE

Enclose the following items with this application:

1. Logo used by manufacturer.

2. Check, cashier’s check or money order made payable to PA Department of Revenue in the amount of the total application fees.

3. Copy of Fictitious Name Registration Form, Department of State Registry Statement or other similar registration. Out-of-state corporations are

required to submit a copy of Certificate of Authority.

4. Schedule A - List of all owners, partners or if incorporated, officers, directors or shareholders controlling 10 percent (10%) or more outstanding stock.

5. Schedule B - List of all distributor’s or manufacturer’s representatives.

6. Schedule C - List of all small game manufacturers with whom distributors do business.

7. Schedule D - List of all states wherein business is conducted regarding small games of chance.

8. Schedule E - List of all approved small games of chance.

9. Application must be notarized in Section IV.

10. Copy of constitution and by-laws or corporate charter (required for initial applications or when data changes).

11. Corporations renewing may submit a notarized statement indicating that no changes have been made to the corporate officers or by-laws in lieu of

#10.

•

The Bureau of Business Trust Fund Taxes, Miscellaneous Tax Division, must be notified of changes to the information included on this application.

•

Questions pertaining to small games of chance and this application can be referred to (717) 787-8275 or the address below.

•

Mail the application and other documents listed above to:

PA Department of Revenue

Bureau of Business Trust Fund Taxes

PO Box 280906

Harrisburg PA 17128-0906

SECTION IV.

CERTIFICATION

I certify that the following tax statements are true and correct:

All PA state tax reports and returns have been filed.

All PA state taxes due have been paid, are subject to timely administrative or judicial appeal or are subject to a duly approved deferred payment plan

(copy enclosed).

I certify that no officer, director or other person in a supervisory or management position or employee eligible to make sales on behalf of this

business:

(i) has been convicted of a felony in a state or federal court within the past five years; or

(ii) has been convicted within ten years of the date of application in a state or federal court of a violation of the Bingo Law or Local Option Small Games of

Chance Act or a gambling-related offense under Title 4 or Title 18 of the Pennsylvania Consolidated Statues or other comparable state or federal law.

(iii) has not been rejected in any state for a distributor’s license or manufacturer’s certificate, or equivalent thereto.

I declare that I have examined this application, including schedules and accompanying statements, and to the best of my knowledge and

belief it is true, correct and complete.

Name of individual in Schedule A (Please Print)

Signature

PLEASE SIGN AFTER PRINTING

SSN

Title

Telephone Number

Date

Notary Public