Form Rb-40 - List Of Bingo Workers
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Illinois Department of Revenue
RB-40
List of Bingo Workers
Read this information first
In order for the individuals listed in Step 2 to legally participate in the management or operation of your bingo games, all requested information
must be complete. In addition, a presiding officer must sign this form.
Note:
If, at a later date, you need to revise any information you have submitted on this form, you must file a new Form RB-40.
Step 1: Write your bingo license number
1 Bingo license no. B - ____________
Step 2: List those who will participate in your bingo games
List below the individuals who will participate in the management or
constitute participation in the management or operation of a
bingo game. The following individuals are ineligible to work bingo
operation of your bingo games. If more than 24 individuals will be
games: those who are professional gamblers, those who have been
participating in such activities, additional Forms RB-40 must be
convicted of a felony, or those who have been convicted of any
completed. Setting up, cleaning up, selling concessions, working in
violation of the Criminal Code of 1961, Article 28.
the kitchen, or providing security for persons or property does not
1 _______________________________________________
7 _______________________________________________
Name (print or type)
Name (print or type)
_______________________________________________
_______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
2 ______________________________________________
8 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
_______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
3 ______________________________________________
9 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
4 ______________________________________________
10 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
5 ______________________________________________
11 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
6 ______________________________________________
12 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
This form is authorized as outlined by the Bingo License and Tax Act. Disclosure of this information is REQUIRED. Failure to provide
RB-40 (R-8/01)
information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-2750
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