Form Cg-21 - Indiana Annual Bingo And/or Pull Tab License Gross Receipts Report
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4CG-21
Indiana Annual Bingo and/or Pull Tab
For Official Use Only
State Form 47835
Date Received _____________
License Gross Receipts Report
(R5/ 7-05)
Reviewed By ______________
Date Entered ______________
The reporting period for this form is the 12-month annual bingo license accounting period. This form must be filed
with your Annual Gaming License Financial Report, Form CG-8, by the 10th day of the month in which your license expires.
Organization Name (Please Type or Print)
Taxpayer Identification Number (TID)
Street Address
City
State
Zip Code
County
First read the instructions on page 3, then complete Schedules 1, 2, 3 and 4 (on pages 2 and 4).
1
1.
Enter gross charity gaming revenue (less prize payout) from page 2, Schedule 3, line 5C .....
2
2.
Enter amount from page 4, Schedule 4, line 1(i) .................................................................
3
3.
Add lines 1 and 2 and enter total here ...............................................................................
4.
Divide line 1 by line 3. Enter the percentage rounded to two numbers (for example, .414
4
%
rounds to 41%, and .875 rounds to 88%) ...........................................................................
5.
Is line 4 equal to 90% (.90) or more?
Yes
No If yes,
5
multiply line 1 by 60% (.60) and enter the result here .....................
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 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 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 the 10th day of the month in which your license expires.
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
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CG-21 (1)
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Parent category: Financial