Form Cg-21 - Indiana Annual Bingo License Gross Receipts Report
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3Form
Indiana Annual Bingo License
For Official Use Only
Date Received _____________
CG-21
Gross Receipts Report
Reviewed By ______________
Revised 3/97
SF-47835
Date Entered ______________
The reporting period for this form is the 12-month annual bingo license accounting period. This form must be filed
with your Annual Bingo License Financial Report, Form CG-8, by the 10th day of the month in which your license expires.
Organization Name (Please Type or Print)
Indiana Not-for-Profit Number
Street Address
City
State
Zip Code
County
First read the instructions on page 3, then complete Schedules 1, 2, 3 and 4 (on pages 2 and 4).
1
1.
Enter gross charity gaming revenue (less prize payout) from page 2, Schedule 3, line 5C ......
2
2.
Enter amount from page 4, Schedule 4, line 1(i) ...................................................................
3
3.
Add lines 1 and 2 and enter total here ..................................................................................
4.
Divide line 1 by line 3. Enter the percentage rounded to two numbers (for example, .414
4
%
rounds to 41%, and .875 rounds to 88%) .............................................................................
G
G
5.
Is line 4 equal to 90% (.90) or more?
Yes
No If yes,
5
multiply line 1 by 60% (.60) and enter the result here .....................
General Information
C
If line 4 is 90% or more, then your organization is required to donate at least 60% of your gross gaming receipts (less
prize payouts), which is the amount on line 5 above. These donations must be in accordance with the lawful purpose of
your organization and must be made to another qualified organization(s) that is not an affiliate, parent, or a subsidiary
of your organization. These donations must be made by the 10th day of the month in which your license expires. A
qualified organization: 1) is a bona fide religious, educational, senior citizens, veterans, or civic organization operating
in Indiana that is exempt from taxation under Section 501 of the Internal Revenue Code; or 2) may be a bona fide
political organization operating in Indiana that produces exempt function income; or 3) may be a hospital, health facility
or psychiatric facility licensed under IC 16-21-2, 16-28-2 and 16-28-2, respectively; and must have been continuously
in existence for at least five years or be affiliated with a parent organization that has been is existence for at least five
years.
C
Schedule CG-DIST must be attached to this form.
C
This form must be filed by the 10th day of the month in which your license expires.
We certify under penalty of perjury that the above organization is a qualified organization, and that there are no
misrepresentations or falsifications in the information stated. We understand false or misleading statements can cause
the revocation of future license(s).
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Signature of Presiding Officer
Date
N
Signature of Secretary
Date
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