Form Le-21a - Quarterly Report Segregated Bank Account Information Instruction
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1State of Colorado
Office of the Secretary of State
LE-21a: Quarterly Report
Division of Licensing and
Enforcement, 1700 Broadway,
Segregated Bank Account Information
Suite #300, Denver, CO 80290
"Pursuant to Section 12-9-108 (3)(a), C.R.S., of the Bingo and Raffles Law, all money received must
be deposited in a segregated checking or savings account of the licensee. Failure to do so may
result in sanction by the Secretary of State, Division of Licensing and Enforcement."
CONFIDENTIAL, NOT FOR PUBLIC DISTRIBUTION
This form will NOT be scanned for public viewing
1. License Number
2. Quarter Year
3. Quarter
4. Due Date
5. Organization Name
6. Mailing Address
7. City, State, Zip
Bingo/Raffle:
Checking
Savings Progressive
(select one)
8. Bank Name:
9. Acct. No.
10. Address:
City:
Zip:
Bingo/Raffle:
Checking
Savings Progressive
(select one)
8. Bank Name:
9. Acct. No.
10. Address:
City:
Zip:
Bingo/Raffle:
Checking
Savings Progressive
(select one)
8. Bank Name:
9. Acct. No.
10. Address:
City:
Zip:
(Provide bank account information here and it will be maintained in a separate file. It is public information and can
be accessed upon request but will not be made available to the general public )
LE 21a Quarterly Report Bank Account Information Instructions
1. Enter the current Colorado Bingo/Raffles License Number
2. Enter the quarter year being reported
3. Enter the current quarter
4. Enter the due date
5. Enter the organization's name
6. Enter the organization's address
7. Enter the city, state, and zip code
L:GamesManagerTraining/LE21aGMT-Instr/Mar08/lm
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Parent category: Business