Fillable Form Cg-21 - Annual License Gross Receipts Report printable pdf download

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CG-21, ANNUAL LICENSE GROSS RECEIPTS REPORT

State Form 47835 (R6 / 6-11)

For Official Use Only

INDIANA GAMING COMMISSION

Date Received _____________

Reviewed By ______________

Date Entered ______________

INSTRUCTIONS: The reporting period for this form is the 12-month annual event license accounting period and must be filed by the 10th day of the month

in which your license expires.

Organization name (please type or print as it appears on your qualification application)

Email address

Address of principal office (number and street; do not enter a P.O. Box Number)

Federal identification number (FID)

City

State

ZIP code

County

First read the instructions on page 4, then complete Schedules 1, 2, 3 and 4 on pages 2 and 3

Enter gross charity gaming revenue (less prize payout) from page 3, Schedule 3, line 5C ...............................................

Enter amount from page 3, Schedule 4, Column (h) ...........................................................................................................

Add lines 1 and 2 and enter total here ..............................................................................................................................

Divide line 1 by line 3. Enter the percentage rounded to two numbers (for example, .414 rounds to 41%, and .875

rounds to 88%) ..................................................................................................................................................................

Is line 4 equal to 90% (.90) or more?

Yes

If yes,

multiply line 1 by 60% (.60) and enter the result here

.........................................................

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 the last day of the charity

gaming accounting period. 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 a 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 the 10th day of the month in which your license expires along with the CG-8 and renewal application.

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 the completed report to:

Indiana Gaming Commission, Charity Gaming Division, 101 W. Washington Street, East Tower, Suite 1600, Indianapolis, IN 46204

Telephone: (317) 232-4646

Fax: (317) 232-0117

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CG-21

Form Cg-21 - Annual License Gross Receipts Report

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