Form Cg-4 - Charity Game Night License Application - Indiana Department Of Revenue
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4For Official Use Only
Form
License Fee Paid _____________
CG-4
Indiana Department of Revenue
Date Received ______________
Rev. 6-96
Reviewed By ______________
SF-45383
Charity Game Night License Application
Date Entered _______________
You must file this application at least six (6) weeks before your scheduled charity game night event.
1. Name of organization (please type or print)
STOP! Get Charity
Gaming Publication 2
2. Previous name of organization (if name changed)
for more information.
3. Street address of principal office (as it appears on the Charity Gaming Qualification Application, Form CG-1)
City
State
Zip Code
County
Daytime Telephone Number
(
)
4. On what date and during what hours will your charity game night event be conducted? (A.M. establishes the midnight hour, P.M. establishes
the noon hour.) (This session can run for no more than 8 consecutive hours.)
Date _________________
Hours ___________ ___M to ____________ ___M
5. Street address of the facility where the charity game night event will be conducted and the DBA name (Doing business as) if applicable.
City
State
Zip Code
County
Daytime Telephone Number
(
)
Attach additional sheets if necessary
Leasing Information
to supply all information for each line.
6. Does your organization own _____, lease (rent) _____, or use a donated _____ facility where the licensed event will be conducted? (Check
one.) If leased (rented), enter name and address of lessor and attach a copy of your signed lease agreement. If donated, attach a notarized
statement from the donor that the facility is being offered rent free. NOTE: Check this box
if the rented facility is being used for an
annual convention or other yearly meeting of your organization's (or your affiliate's) membership.
Name of Lessor (Full Legal Name)
Address
City
State
Zip Code
County
Daytime Telephone Number
(
)
7. Is any tangible personal property (i.e. tables, chairs, roulette wheel, etc.) being leased or donated to you for this event?
Yes
No
If you answered yes, , list the name and address of the lessor or donor. Attach a signed copy of the lease agreement or donation statement
from the donor.
Name
Address
City
State
Zip Code
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