Form 50j - Nebraska Application For Special Event Bingo Permit - 2011
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4Nebraska Application for Special Event Bingo Permit
FOrM
• Incomplete applications will be returned.
50J
• Include $15 permit fee.
1 Do you hold or have you previously held a Nebraska ID Number?
PLeASe DO NOT wriTe iN THiS SPACe
YES
NO
If Yes, give number
PRINT FORM
RESET FORM
3 County of Organization’s Location in
2 Federal Employer ID Number
Nebraska
OrGANiZATiON’S NAMe AND LOCATiON ADDreSS
OrGANiZATiON’S NAMe AND MAiLiNG ADDreSS
Name
Name
Number and Street
Street or Other Address
City
State
City
Zip Code
Zip Code
State
5 Is your organization currently exempt under Internal Revenue Code § 501?
4 Indicate the number of years your
organization has been in existence
YES
NO
If Yes, indicate subsection: 501(c) ________________________________
in Nebraska:
If Yes:
• Submit a copy of the exemption determination letter issued by the IRS;
• Submit a copy of the page of the Official Catholic Directory where your organization’s name appears; Or
• Indicate the group exemption number assigned by the IRS, and you do not need to answer lines 6 and 7.
if No, you must complete lines 6 and 7.
6 Provide a brief explanation of the purpose for which your organization was created. Attach articles of incorporation or bylaws.
7 Provide examples of the types of activities conducted by your organization. Attach additional sheets, if necessary.
8 Does your organization currently hold any charitable gaming licenses issued by the Nebraska Department of Revenue?
YES
NO
If Yes, indicate the types of licenses held:
Bingo
Pickle Card
Lottery/Raffle
Other, explain
9 Provide the name and a brief description of the special event at which you wish to conduct bingo.
10 Will anyone under 18 years of age be allowed to play bingo?
YES
NO
If yes, will alcohol be served?
YES
NO
11 Indicate location of the special event bingo games.
Name
Address
City
State
Zip Code
County
12 Indicate the dates and times that bingo is to be conducted (aggregate maximum of two events over 14 days).
Event Dates
Time First Number Called
Ending Time
Event Dates
Time First Number Called
Ending Time
to
to
to
to
13 Provide the name, address, and telephone number of the individual in charge of conducting the special event bingo games.
(
)
Name
Address
City
State
Zip Code
Telephone Number
E-Mail Address
Under penalties of law, I declare that I have examined this application and, to the best of my knowledge and belief, it is correct and complete. I will comply
with all the provisions of the Nebraska Bingo Act pertaining to special event bingo, and the rules and regulations adopted under this Act.
sign
(
)
here
Telephone Number
Home
Signature of Officer of the Organization
Title
Date
(
)
Telephone Number
Work
Email Address
Mail the original application and $15 fee to:
NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, PO BOX 94855, LINCOLN, NE 68509-4855
reTAiN A COPy FOr yOUr reCOrDS.
Special Event Bingo Information Guide, June 15, 2011, Page 3
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