Previous Charity Gaming License Information
23. Has your organization been previously licensed by the Indiana Department of Revenue to conduct raffle events?
Yes* __________
No __________
*If yes, what was the previous raffle 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 Raffle License is $25. All other Raffle License fees will be based on the gross receipts from the last raffle 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 falsifica-
tions 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 Revenue
Date
Signature of Officer
Officer's County of Revenue
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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