Form L-2058 - Application For Bingo License Non Profit Organization - 2008

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1350
1350
STATE OF SOUTH CAROLINA
SOUTH CAROLINA DEPARTMENT OF REVENUE
L-2058
APPLICATION FOR BINGO LICENSE
NON PROFIT ORGANIZATION
(Rev. 9/26/08)
4137
For the Year of __________
This application must be received in the Columbia office of the Department of Revenue no
Do Not Write in This Space
later than 45 days prior to renewal date. Mail application and make check payable to the
General fund $
Cash-M. O.-Check
South Carolina Department of Revenue, Regulatory Division, Bingo Enforcement, Columbia ,
SC 29214-0026, telephone 803-898-5393.
Audited by
Date
The application must be filed in original form, and all signatures must be original. We cannot
accept carbon or photo copy applications nor stamped, traced, facsimile, or other signatures.
File #
This application is for the class license as checked (one only):
1-4-2561
1) Class AA - $4,000.00 fee
3) Class C - no fee
5) Class F- $100.00 fee
2) Class B - $1,000.00 fee
4) Class E - $500.00 fee
1. Name as Chartered with SC Secretary of State
Street Address
State
City
Zip
Mailing Address
City
State
Zip
Phone Number
FEI #
SC Withholding #
2. Enter the date the organization was chartered by SC Secretary of State's Office ____________________.
Attach a copy of the organization's SC charter and a copy of the by-laws. If the organization operates in SC under
a group ruling or charter from a national organization, you must attach a currently dated letter from the national
organization organization that states the organization is under the direct policy control of the national organization
and that the organization is in good standing. Give the following information on the national organization.
Name
Mailing Address
County
City
State
Zip
3. State the Doing Business as Name, address and times you intend to conduct Bingo Games.
Doing Business As Name
Street Address
City
Zip
County
State
Day(s) of the Week
Hours of Operation
Phone Number
4. If you have been added within the past year to your national organization group ruling, has the national organization
notified the IRS of your addition?
Yes
No
5. Is your organization operating exclusively for charitable, religious or fraternal purposes and exempt from federal
income taxes?
Yes
No
A copy of the Internal Revenue Service letter must be attached.
6. Does your organization file a SC990T with the Department of Revenue?
Ye s
No
41371022

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