Form Rb-3 - Bingo Application For License - Illinois Department Of Revenue
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1
2Illinois Department of Revenue
RB-3
Bingo Application for License
License no. ____________________
License issued _________________
Do not write above this line.
Read this information first
To qualify for a license to conduct bingo games, your organization
• not have any officers, directors, employees, workers, or operators
must
of bingo who have been convicted of a felony or who have been
• be not-for-profit;
convicted of a gambling offense;
• have been organized and in existence in Illinois for at least the
• not compensate operators or workers who participate in the
past five years or affiliated and chartered with a national organiza-
management or operation of bingo; and
tion for two years and have had members carrying out the
• post a surety bond in the amount of the anticipated average
organization’s goals during either period;
quarterly tax liability if you are a new applicant.
Step 1: Identify your organization
List all of the following numbers that your organization
Organization name _______________________________________
has been assigned.
Physical address _________________________________________
Number and street
FEIN ____ ____ - ____ ____ ____ ____ ____ ____ ____
_________________________________________________________
City
State
ZIP
IBT number ____ ____ ____ ____ - ____ ____ ____ ____
( _____ ) ______________________
________________________
County
Telephone number
Charitable games license no. ___________________________
Mailing address __________________________________________
Number and street or post office box
Pull tabs license no.
_________________________________
_______________________________________________________
City
State
ZIP
Step 2: Tell us about your organization
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3
Check the type of your nonprofit organization.
How long has your organization had members carrying out its
____ charitable
____ religious
goals?
_________________
____ educational
____ senior citizen
4
____ fraternal
____ veterans
Is your organization incorporated?
_____ yes
_____ no
____ labor
____ youth athletic
If “yes,” in which state and on what date was it incorporated?
(If this is the first time you are applying for this license, attach a
State:_____________________
Date: __________________
copy of your bylaws and constitution or charter.)
(If this is the first time you are applying for this license, attach a
copy of the articles of incorporation.)
2
How many members does your organization have? ___________
Step 3: Tell us about your bingo event
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4
Where will bingo be played?
What are the two time periods bingo will be played?
Number and street _____________________________________
City, state, ZIP_________________________________________
First time period:
_____/_____/_____ to _____/_____/_____
Month
Day
Year
Month
Day
Year
A.M.
A.M.
2
Do you own or lease the premises where bingo will be played?
__ __ : __ __
to __ __ : __ __
P.M.
P.M.
Hour
Minute
Hour
Minute
_____ own
_____ lease
If you lease the premises specifically for the conduct of bingo
Second time period: _____/_____/_____ to _____/_____/_____
Month
Day
Year
Month
Day
Year
games, attach a copy of your lease agreement.
A.M.
A.M.
__ __ : __ __
to __ __ : __ __
P.M.
P.M.
Hour
Minute
Hour
Minute
If the provider supplies services or products that are not included
in the lease, send us a list of the items and their cost with this
Note: If the last date is not known at this time, you must let us
application. Write the provider’s license number. ______________
know the exact date 30 days before the event.
3
5
Will you conduct bingo events more than twice a year?
Make your check for $50 payable to “Illinois Department of
_____ yes
_____ no
Revenue.” Go to Step 4.
If “yes,” go to Item 6 on the back. You are applying for a regular
bingo license.
Please turn this application over and
If “no,” go to Item 4. You are applying for a limited bingo license.
continue completing Steps 3-5.
This form is authorized as outlined by the Bingo License and Tax Act. Disclosure of this information is REQUIRED. Failure to provide
RB-3 Front (R-1/95)
information could result in this form not being processed. This form has been approved by the Forms Management Center.
IL-492-1359
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