Form G-22 - Single Event Annual Gross Receipts Report
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CG-22, SINGLE EVENT ANNUAL GROSS RECEIPTS REPORT
For Official Use Only
State Form 47862 (R3 / 6-11)
Date Received _____________
INDIANA GAMING COMMISSION
Reviewed By ______________
Date Entered _______________
INSTRUCTIONS: The reporting period for this form is July 1 of the previous year through June 30 of the current year. Annual license holders: DO NOT
complete this form; complete Form CG-21. This form must be filed by August 15. Attach additional sheets if necessary.
Email address
Organization name (Please type or print as it appears on your qualification application)
Address of principal office (number and street; do not enter a P.O. Box Number)
Federal identification number (FID)
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.
Enter gross charity gaming revenue (less prize payout) from page 2, Schedule 1, line 1C..................................................
1
Enter amount from page 2, Schedule 2, Column (h) ..........................................................................................................
2
Add lines 1 and 2 and enter total here ...............................................................................................................................
3
Divide line 1 by line 3. Enter the percentage rounded to two numbers (for example, .414 rounds to 41%, and .875
4
%
rounds to 88%) ..................................................................................................................................................................
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 pertaining to line 5
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.
I certify under penalty of perjury, that I have examined this report and to the best of my knowledge and belief, it is complete and correct.
Signature of Presiding Officer
Printed name
Title
Daytime telephone number
Date (month, day, year)
Printed name
Signature of Secretary
Daytime telephone number
Date (month, day, year)
Mail to: Indiana Gaming Commission, Charity Gaming Division, 101 W. Washington St., East Tower, Suite 1600, Indianapolis, IN 46204
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CG-22
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