Form Fs-92 - Bingo Card Refund Request Page 2
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4STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
FS-92
(Rev. 8/5/09)
BINGO CARD REFUND REQUEST
2081
Organization:
Name:
License #:
Mailing Address:
City:
State:
ZIP:
Promotor:
Name:
License #:
Mailing Address:
City:
State:
ZIP:
Distributor:
Name:
License #:
Mailing Address:
City:
State:
ZIP:
Total of Value of Cards from Worksheet Summary
Bingo Tax Refund Rate
7.40
7.40%
Bingo Tax Refund Due
I,
being an authorized representative of the above named organization and/or promoter
request a refund of tax paid on bingo cards described on this document. These cards were purchased for use by the
above organization and the above information is true and correct to the best of my knowledge.
Print Name
Title
Date
Signature
I,
have received the bingo cards described on this document.
Signature
Title
Date
Signature (2 signatures required over $1,000)
Title
Date
Manager/Supervisor Signature
Title
Date
For Department Use Only:
Last Purchase
Date Paid
Other Liabilities
SC DOR Employee
20811022
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Parent category: Financial