Form Cg-9 - Indiana Charity Gaming License - Single Event Financial Report Page 4
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4License Renewal Fees
If you are not renewing your annual bingo license, no fee will be due. However, this report must be filed with the Department within
The first license fee in any license category is $25.
ten (10) days after the expiration date shown on the license. Check this box
if you are not renewing your annual bingo license.
For the next license in this same category, the license renewal fee is based on the gross receipts from the previous event held in this
You must pay a renewal fee if you want to renew your organization's Annual Bingo License. This fee is based on the gross income
category.
from your bingo events and related activities. Failure to provide this information will result in delays in licensing.
Example: An organization paid the $25 license fee and conducted a raffle event. Later that year, this group wanted to conduct another
Enter the Total Gross Income from Line A of Section B on page 2 of this form............................................ $
raffle event. The license fee would be based on the gross receipts from the previous raffle license. This same group wants to conduct
Find this amount on the chart below in order to determine the dollar amount of your license renewal fee. The corresponding fee is the
a festival event. Because this will be the first time the organization has received a license in the festival license category, the license fee
amount you must send with this financial statement in order to continue conducting your bingo events.
will be $25.
If the amount on Line A of Section B is:
At least
But Less Than The renewal fee is:
1.
Enter the Total Gross Income from Line A
of Section B on page 2 of
$
$
0
25
$
15,000
this form .............................
$
$
$
15,000
25,000
75
$
$
$
$
25,000
50,000
200
2.
Find this amount on the chart to the left in order
$
$
$
50,000
75,000
350
to determine the dollar amount of your license
$
$
75,000
600
$
100,000
renewal fee.
$
$
100,000
900
$
150,000
$
$
150,000
200,000
1,200
$
3.
Enter the corresponding
$
$
200,000
250,000
1,500
$
renewal fee here ..................
$
$
$
$
250,000
300,000
1,800
$
$
$
300,000
400,000
2,500
$
$
400,000
3,250
$
500,000
4.
This
$
$
500,000
5,000
$
750,000
is the amount you must send with the next
$
$
750,000
1,000,000
6,750
$
license application in order to conduct this
$
$
$
1,000,000
1,250,000
8,500
event in the future.
1,250,000
$
$
$
1,500,000
10,000
$
$
1,500,000
12,000
$
1,750,000
$
$
1,750,000
14,000
$
2,000,000
$
$
2,000,000
2,250,000
16,250
$
Keep a copy of this financial report for your
$
$
$
2,250,000
2,500,000
18,500
records. You will need it if you want to conduct
$
$
$
2,500,000
3,000,000
22,500
this event in the future.
3,000,000
$
$
$
------------
25,000
Signature and Notary Statement
Under the penalty of perjury, I have examined this report and, to the best of my knowledge and belief, it is true, complete and correct. I
also have attached charitable contribution listing, Schedule CG-DIST, if applicable.
(
)
Signature of Presiding Officer
Date
Daytime Telephone Number
Subscribed and sworn to before me, a Notary Public in and for _____________________________ County, State of Indiana,
this __________ day of _______________, 20____.
Notary Public, Written Signature
Notary Public, Printed Name
My Commission Expires:
County of Residence:
Mail the completed report and any remittance for the renewal license to:
Indiana Department of Revenue, Charity Gaming Section, 100 N. Senate Ave., Indianapolis, IN 46204
CG-9 (4)
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