Form 201 - R - Charitable Gaming Permit Application Renewal Applicants Only
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12FORM 201 - R
VDACS FINANCE CODE: 988-02199
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526, Richmond, VA 23218
(804) 371-0495
CHARITABLE GAMING PERMIT APPLICATION - RENEWAL APPLICANTS ONLY
General Instructions
A.
Use this application when applying for renewal of a current valid charitable gaming permit.
B.
Complete the entire application and all attachments. DO NOT LEAVE ANY BLANKS.
C.
Place "N/A" if item is not applicable. Please type or print all answers. Do not use pencil.
D.
If needed, attach additional documents or explanation sheets.
E.
Ensure application is signed/dated by the appropriate individual(s).
F.
Enclose a non-refundable $200 application fee payable to: Treasurer of Virginia. Volunteer Fire Departments and Rescue Squads who have been recognized
by their locality in accordance with Section 15.2-955 of the Code of Virginia, and who can provide a copy of the ordinance or resolution of the locality, are
exempt from the application fee.
G.
Retain a copy for your records.
H.
Mail completed application, applicable fee, and all required attachments to: VDACS, Office of Charitable and Regulatory Programs, PO Box 526, Richmond,
Virginia 23218.
I.
Allow 45 days for processing a COMPLETE application. Incomplete applications and not providing applicable attachments will delay the processing.
J.
Ensure that the applicant has included the area code in each instance where a telephone number is requested.
ORGANIZATION INFORMATION
OCRP No.
1.
Organization's Federal Tax Payer Identification Number
2.
Organization's Name:
Mailing Address:
City:
State:
Zip Code:
Telephone:
Email Address:
Web Page:
3.
Organization's Physical Location:
City:
State:
Zip Code:
Telephone:
Title:
Contact Person:
Contact Person's Daytime Contact Number:
Facsimile:
Email Address:
4.
Jurisdiction where the organization regularly
County of:
City of:
meets?
5.
Total No. of Members:
Total No. of Virginia Residents:
Provide a complete list of members who work in the
management and operation of charitable gaming activities,
Membership list attached with all
Yes or No
including name, address, and membership date.
information?
6.
Has there been any change in the organization's Articles of Incorporation, By-
Laws, Charter, Constitution, and any other organizing documents? If yes,
Yes or No
attach applicable documents.
7.
Type of Tax Exempt Status Obtained from IRS
(Mark "X" at the Appropriate Box) :
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8
501
(c)0
TYPE
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Other - Explain on separate page
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 1 of 12
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