Cg-22 State Form 47862 - Indiana Single Event License - Gross Receipts Report - 2005

ADVERTISEMENT

CG-22
Indiana Single Event License
For Official Use Only
Date Received _____________
State Form 47862
Gross Receipts Report
Reviewed By ______________
(R3/ 6-05)
Date Entered _______________
The reporting period for this form is July 1 of the previous year through June 30 of the current year.
Annual Bingo license holders: DO NOT complete this form; complete Schedule CG-21.
This form must be filed by August 15.
Organization Name (Please Type or Print)
Taxpayer Identification Number (TID)
Street Address
City
State
Zip Code
County
The reporting period for the amounts to be entered on Schedules 1 and 2 is July 1 through June 30.
First read the instructions on page 2, then complete Schedules 1 and 2.
1.
Enter gross charity gaming revenue (less prize payout) from page 2, Schedule 1, line 1C ...
1
2.
Enter amount from page 3, Schedule 2, line 1(i) ...............................................................
2
3.
Add lines 1 and 2 and enter total here ....................................................................................
3
4.
Divide line 1 by line 3. Enter the percentage rounded to two numbers (for example, .414
rounds to 41%, and .875 rounds to 88%) ...............................................................................
%
4
5.
Is line 4 equal to 90% (.90) or more?
Yes
No
If yes,
multiply line 1 by 60% (.60) and enter the result here ....................
5
General Information
If line 4 is 90% or more, then your organization is required to donate at least 60% of your gross gaming receipts (less prize payouts),
which is the amount on line 5 above. These donations must be in accordance with the lawful purpose of your organization and
must be made to a qualified recipient(s) that is not an affiliate, parent, or a subsidiary of your organization. These donations must
be made by June 30. A qualified recipient is: 1) a bona fide religious, educational, senior citizens, veterans, or civic organization
operating in Indiana that is exempt from taxation under Section 501 of the Internal Revenue Code, and which must have been
continuously in existence for at least five years or be affiliated with an Indiana parent organization that has been in existence for
at least five years; 2) a bona fide political organization operating in Indiana that produces exempt function income; 3) a hospital or
medical center operated by the federal government; 4) a hospital licensed under IC 16-21; 5) a hospital subject to IC 16-22 or IC 16-
23; 6) a health facility or psychiatric facility licensed under IC 16-28 and IC 12-25, respectively; 7) an activity or program of a local
law enforcement agency intended to reduce substance abuse; 8) a charitable activity of a local law enforcement agency; or 9) a
veterans' home, which is the Indiana Veterans' Home, the VFW National Home for Children, and/or the Indiana Soldiers' and
Sailors' Children's Home. (Note: For the purpose of being a qualified recipient,a veterans' home is not considered to be an
affiliate, a parent, or a subsidiary organization of a qualified organization that is a bona fide veterans' organization.)
Schedule CG-DIST must be attached to this form.
This form must be filed by August 15.
We certify under penalty of perjury that the above organization is a qualified organization, and that there are no misrepresentations or
falsifications in the information stated. We understand false or misleading statements can cause the revocation of future license(s).
Signature of Presiding Officer
Date
Signature of Secretary
Date
Mail to: Indiana Department of Revenue, Charity Gaming Section, 100 N. Senate Ave., Indpls., IN 46204
1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3