Form Cg-Ael - Application For Exemption Letter For Non-Licensed Event July 2005


Indiana Department of Revenue
State Form 51413
Application for Exemption Letter
for Non-Licensed Event
You must file this application at least four (4) weeks before your scheduled event.
Apply for:
Please print or type the following:
• Only one event per day
• Only one event (day) per application
Street Address:
• Do not exceed two consecutive days of
City, State, Zip Code:
Type of Non-Licensed Event:
Daytime Telephone Number: (
(Check only one box)
Contact Person:
Charity Game Night
Contact Person’s Telephone Number: (
Door Prize
Date of Event
Taxpayer Identification Number (TID)
Address of Non-Licensed Event
Zip Code
Attach a lease or notarized donation statement if your organization does not own the property on which the event will be held.
Total value of all prizes awarded (including prizes from
Total value of all prizes to be awarded (including
sales of pull-tabs, punchboards and tip boards) at all
prizes from sales of pull-tabs, punchboards and tip
boards) at non-licensed event listed above:
previously held non-licensed events (within same
calendar year): $
Does your organization own_____, lease_____, or use donated_____ gaming equipment. If leased or donated, attach a copy of
the agreement, not to exceed $50.00, or notarized donation statement.
Enter the name(s) of Operator(s) for this non-licensed event. Detailed information for each Operator must be
completed on the back:
1. Name:
2. Name:
3. Name:
4. Name:
A validated copy of this Application for Exemption Letter must be displayed at the non-licensed event.
Please refer to the Indiana Department of Revenue Charity Gaming Publication 2 regarding prize
limitations, etc.
Officer’s Signature
Officer’s Printed Name
For Department Use Only
This application is not valid unless signed and stamped by the Department.
CG-AEL (1)


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