Form Cg-3 - Special Bingo License Application - 1996 Page 4
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4Previous Charity Gaming License Information
23. Has your organization been previously licensed by the Indiana Department of Revenue to conduct special bingo events?
Yes* __________
No __________
*If yes, what was the previous special bingo license number? _________________________ Date of issue __________
24. Has your organization ever had a prior charitable gaming application denied by the Indiana Department of Revenue or had its license
suspended or revoked? Yes* _______
No _______
*If yes, list the reasons why your license was denied, suspended, or revoked.
License Fee Information
25. The license fee for the first Special Bingo License is $25. All other Special Bingo License fees will be based on the gross receipts from the
last special bingo event. You will find this license fee amount on the back page of the Indiana Charity Games Single Event Financial Report,
Form CG-9. The fee should be paid by a check drawn from your not-for-profit checking account. Make your check payable to: Indiana
Department of Revenue. Do not send cash.
26. Certification
We certify under penalty of perjury that the organization applying is a qualified organization, and there are no misrepresentations or
falsifications in the information stated. We understand false or misleading statements will cause rejection of this application or revocation of
future license(s). We attest that we reside in the same county where the licensed event will be held.
27. Signature of Officer
Officer's County of Residence
Date
Signature of Officer
Officer's County of Residence
Date
Send this application and appropriate fee to:
Indiana Department of Revenue
Charity Gaming Section
100 North Senate Avenue, Room N-203
Indianapolis, IN 46204
Phone: (317) 232-4646
First time applicants must enclose a licensing fee of $25.00.
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