Form Cg-1 - Indiana Charity Gaming Qualification Application
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2Form
Indiana Charity Gaming
CG-1
Qualification Application
Revised 6-96
SF-45380
Do not write above
Allow 6 weeks for processing. If the application is incomplete, it will be returned to you and processing will be delayed. Please print or type.
Mail the completed application to:
Indiana Department of Revenue
Charity Gaming Section
100 North Senate Avenue, Room N-203
Indianapolis, IN 46204
Phone: (317) 232-4646
Authority: IC 4-32
1. Organization name (please type or print)
2. Organization telephone number
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Street address of principal office (also enter a P.O. Box Number if applicable.)
City
State
Zip Code
County
3. Federal Identification Number
4. Indiana Taxpayer Identification Number
5. Indiana Not-for-Profit Tax Registration Number
6. Check the type of organization:
Religious
Educational
Civic/Fraternal/Charitable
Veterans
Senior Citizens
Political
7. Applicant organization information:
a. Date organization formed ________________ A copy of the organization's bylaws, constitution, or articles of incorporation must be
attached.
b. Date incorporated _________________ (If not incorporated, enter NA.)
c. How many years has the organization been in active, continuous existence? ________________ Verification must be attached. See
instructions on page 3.
d. Number of active members ________________
8. Name and address of current officers (attach additional sheets if necessary.)
Name
Address
Title
Home telephone number
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Parent category: Financial