Form Cg-1 - Indiana Charity Gaming Qualification Application Page 2
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29. Parent organization information
a.
Is your organization affiliated with a parent organization?
Yes
No
If 9a is Yes, complete 9b and 9c.
If 9a is No, go to number 10.
b.
Parent organization name
Federal Identification Number
Street address of principal office (do not enter a P.O. Box Number.)
City
State
Zip Code
County
Parent organization telephone number
(
)
c.
How many years has the parent organization been in active, continuous existence? ____________
10. Is your organization exempt from federal income tax under Section 501 of the Internal Revenue Code?
Yes
No
If you answered yes, attach a copy of the favorable tax exempt status letter from the Internal Revenue Service. If
application has been made, but you have not yet received the letter, attach a copy of the application plus a copy of the check used to pay the
application fee. If you answered no, your organization is not eligible to conduct charity gaming activities in Indiana.
11. List the proposed operators of charity gaming event(s): (attach additional sheets if necessary)
No. of
active
yrs. with
Social Security
Date of
group
Name
Home Address
Telephone Number
Number
Birth
(
)
(
)
(
)
(
)
(
)
12. Certification
We certify under penalty of perjury that the organization applying is a qualified organization and that there is no misrepresentation or
falsification in the information stated. We certify that to the best of our knowledge the operators of the charity game events have not been
convicted of any felonies. We understand that false or misleading statements will be cause for rejection of this application or revocation of
future licenses.
13. Signature of Presiding Officer
Date
Signature of Secretary
Date
Do Not send a payment with this form.
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