Form 201 - R - Charitable Gaming Permit Application Renewal Applicants Only Page 2
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12ORGANIZATION INFORMATION
Type of Organization - Please
8.
Veterans
Community
Fraternal
place an "X" in the appropriate
box.
Religious
Charitable
Educational
Other - Explain:
9.
In the last three years, has the organization had a 501(c) status with the
If yes, please explain on a
Internal Revenue Service revoked or suspended?
separate page.
Yes or No
10.
Is the organization in compliance with Federal and State law relative to the
filing, in the last three tax years, of mandated Federal and State tax returns
If no, please explain on a
(i.e ., 990, 990EZ, 990T, 990PF, etc.)?
Yes or No
separate page.
11.
What is the tax period and year of the organization's most recently filed
Internal Revenue Service tax Form 990 (including, but not limited to, Form
990, 990EZ, 990 PF, 990T) or applicable tax return that has been officially
filed and received by the IRS? If no return has been filed, please explain on
a separate page.
Month/Date/Year
Amount
reported on
Line 9.a. of the
Please provide the Total Gross Revenue from Special Events and Activities
Form 990
(Charitable Gaming) as reported to the Internal Revenue Service relative to
the charitable gaming activities conducted by the organization on Form 990 -
Amount
Return of Organization Exempt from Income Tax. If the organization has
reported on
been formally recognized by the IRS as a church, then attach the most
Line 6. of the
recent Statement of Income and Receipts, and Balance Statement.
Short Form 990
12.
If your organization is a part of or related to a national office of an
organization (See . Section 18.2-340.24.A.1.(i.), Code of Virginia, 1950, as
amended), please provide a letter of good standing from the national
organization which indicates that your organization is currently covered by
the group exempt ruling. If the national and/or state office has provided this
information to the Office for the current year, please select N/A (not
applicable).
Yes or No
Copy attached?
If this is not applicable to your organization, place an "X" in the box.
Not Applicable
13.
Is your organization recognized as a corporation or a form of limited liability
If no, explain on a separate page
how the organization is exempt
company, as defined by the Code of Virginia, and authorized to do business
from this requirement.
in Virginia?
Yes or No
Yes
If you answered yes to Item No. 13, is the name as registered at the Virginia
State Corporation the same as provided under Item No. 2 of this application.
If no, please print registration name below.
Yes or No
14.
If you answered yes to Item No. 13, is your organization in good standing
If no, please explain on a
with the Virginia State Corporation Commission?
separate page.
Yes or No
15.
Is the organization registered and in good standing with the Virginia
If no, please explain on a
separate page how the
Department of Agriculture and Consumer Services to solicit charitable
organization is exempt from
contributions in Virginia?
Yes or No
registration.
If you answered Yes to Item No. 15, is the name as registered at the Virginia
Department of Agriculture and Consumer Services the same as provided
under Item No. 2 of this application. If No, please print registration name
below.
Yes or No
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 2 of 12
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