Form Rcg-32 - Charitable Games Event Workers Attendance List (Page 2 of 2) in pdf

Step 2: Complete the workers’ perjury statement (continued)

Under penalties of perjury, I certify that I worked a charitable games event for the organization on the date(s) identified in Step 1. I also certify

that I have not participated in the management or operation of more than 12 charitable games events within this calendar year; that I have not

received any remuneration or compensation directly or indirectly for participating in the management or operation of any charitable games event;

that I am not a professional gambler or have not been convicted of any felony within 10 years of the date of this certification or of any violation of

the Criminal Code of 1961, Article 28; and that I am not employed by or do not have any interest in any person, firm or corporation that holds a

charitable games provider’s or supplier’s license.

13 _______________________________________________ 20 _______________________________________________

Worker’s name

______ - ____ - ________

Social Security number

_______________________________________________

Worker’s signature

Date

Worker’s signature

Date

14 _______________________________________________ 21 _______________________________________________

Worker’s name

______ - ____ - ________

Social Security number

_______________________________________________

Worker’s signature

Date

Worker’s signature

Date

15 _______________________________________________ 22 _______________________________________________

Worker’s name

______ - ____ - ________

Social Security number

_______________________________________________

Worker’s signature

Date

Worker’s signature

Date

16 _______________________________________________ 23 _______________________________________________

Worker’s name

______ - ____ - ________

Social Security number

_______________________________________________

Worker’s signature

Date

Worker’s signature

Date

17 _______________________________________________ 24 _______________________________________________

Worker’s name

______ - ____ - ________

Social Security number

_______________________________________________

Worker’s signature

Date

Worker’s signature

Date

18 _______________________________________________ 25 _______________________________________________

Worker’s name

______ - ____ - ________

Social Security number

_______________________________________________

Worker’s signature

Date

Worker’s signature

Date

19 _______________________________________________ 26 _______________________________________________

Worker’s name

______ - ____ - ________

Social Security number

_______________________________________________

Worker’s signature

Date

Worker’s signature

Date

Step 3: Sign below

Under penalties of perjury, I certify that Step 2 on all Forms RCG-32 submitted with Form RCG-18, Charitable Games Tax Return and Report,

contains an accurate and complete listing of all persons who participated in the management or operation of the charitable games event(s) for

which Form RCG-18 is filed. I certify that these persons are bona fide members, volunteers, or employees of the licensed organization identified

in Step 1; that none of them participated in the management or operation of more than 12 charitable games events within this calendar year;

and that none of them received any remuneration or compensation directly or indirectly for participating in the management or operation of the

charitable games event conducted by the licensed organization. I also certify that my organization has complied with all of the provisions of the

Charitable Games Act.

President’s signature _______________________________________

Date ____ / ____ / ____

This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this information is required.

Failure to provide information may result in this form not being processed and may result in a penalty.

RCG-32 back (R-01/14)