Form Pt-6 - Pull Tabs Application For License Form - Illinois Department Of Revenue
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1
2Illinois Department of Revenue
PT-6
Pull Tabs Application for License
License no. ____________________
License issued _________________
Do not write above this line.
Read this information first
To qualify for a license to sell pull tabs, your organization must
• not have any officers, directors, employees, or persons participat-
• be not-for-profit;
ing in the management or operation of pull tabs and jar games
• have been organized and in existence in Illinois for at least the
who have been convicted of a felony within the last 10 years or
past five years or affiliated with and chartered by a national
who have been convicted of a gambling offense; and
organization for two years and have had members carrying out
• not compensate persons participating in the management or
the organization’s goals during either period;
operation of pull tabs and jar games.
Step 1: Identify your organization
List all of the following numbers that your organization
Organization name _______________________________________
has been assigned.
Physical address _________________________________________
Number and street
FEIN ____ ____ - ____ ____ ____ ____ ____ ____ ____
_________________________________________________________
City
State
ZIP
Illinois business tax number ___ ___ ___ ___ - ___ ___ ___ ___
( _____ ) ______________________
________________________
County
Telephone number
Bingo license no.
____________________________________
Mailing address __________________________________________
Number and street or post office box
Charitable games license no. ___________________________
_______________________________________________________
City
State
ZIP
Step 2: Tell us about your organization
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3
Check the type of your nonprofit organization.
How long has your organization had members
____ charitable
____ religious
carrying out its goals? ___________________
____ educational
____ senior citizen
4
____ fraternal
____ veterans
Is your organization incorporated?
_____ yes
_____ no
____ labor
____ youth athletic
If “yes,” in which state and on what date was it incorporated?
(If this is the first time you are applying for this license, attach a
State: _____________________
Date: __________________
copy of your bylaws and constitution or charter.)
(If this is the first time you are applying for this license, attach a
copy of the articles of incorporation.)
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How many members does your organization have? __________
Step 3: Tell us about people in your organization
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2
Who is responsible for filing tax returns?
Who should we contact in case of questions or problems?
Name ______________________________________________
Name ______________________________________________
Number and street ____________________________________
Number and street ____________________________________
City, state, ZIP _______________________________________
City, state, ZIP _______________________________________
Daytime telephone (______)_____________________________
Daytime telephone (______)_____________________________
Please turn this application over and continue completing Steps 3-5.
This form is authorized as outlined by the Pull Tabs and Jar Games Act. Disclosure of this information is REQUIRED. Failure to provide information
PT-6 Front (R-4/01)
could result in this form not being processed. This form has been approved by the Forms Management Center.
IL-492-2094
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