Form Rcg-1 - Charitable Games Application For License
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1
2Illinois Department of Revenue
RCG-1
Charitable Games Application for License
Read this information first
To qualify for a license to conduct charitable games, your organization must
• be non-profit and have a federal exemption letter 501(c)(3), 501(c)(4), 501(c)(5), 501(c)(8), 501(c)(10), or 501(c)(19);
• have been organized and in existence in Illinois for at least the past five years or affiliated with and chartered by a national organization for
two years and have had members carrying out the organization’s goals during the applicable period; and
• not have any officers, directors, employees, workers, or operators of charitable games who have been convicted of a felony within the last 10
years or who have been convicted of a gambling offense.
We must receive your application at least 30 days prior to the first event you request. You must answer all questions on this application
(write N/A if not applicable) and attach all required documentation. We cannot issue a license to you if these requirements are not met.
Step 1: Identify your organization
List all of the following numbers that your organization has been
Organization name: ______________________________________
assigned.
Address: ______________________________________________
FEIN: ______ - __________________
Street address
______________________________________________________
License number: ________________________
City
State
ZIP
Phone: (_____) _____ - ________ Fax: (_____) _____ - ________
Account ID: ____________ - ____________
Mailing address: ________________________________________
Contact for this form: _____________________________________
Street address or PO Box number
______________________________________________________
Phone: (_____) _____ - ________
City
State
ZIP
Step 2: Tell us about your organization
1
2
Is your organization exempt from paying federal income tax under
Is your organization incorporated? _____ yes _____ no
Sections 501(c)(3), 501(c)(4), 501(c)(5), 501(c)(8), 501(c)(10), or
(If this is the first time you are applying for this license, attach a
501(c)(19)?* _____ yes _____ no
copy of the articles of incorporation.)
*Your organization must be classified under one of the sections
listed above to qualify for a Charitable Games license.
Attach Form 501-C from the Internal Revenue Service.
Step 3: Identify your officers and the person in charge* of conducting the charitable games
3
Provide the following information for the organization’s officers and person in charge of conducting the charitable games.
a
c
President’s name _____________________________________
Treasurer’s name _____________________________________
Social Security number ______ - ____ - ________
Social Security number ______ - ____ - ________
Street address _______________________________________
Street address _______________________________________
City, state, ZIP _______________________________________
City, state, ZIP _______________________________________
Birth date ___ /___ / _______
Phone (____) ____ - _______
Birth date ___ /___ / _______
Phone (____) ____ - _______
b
d
Secretary’s name _____________________________________
Person-in-charge’s name _______________________________
Social Security number ______ - ____ - ________
Social Security number ______ - ____ - ________
Street address _______________________________________
Street address _______________________________________
City, state, ZIP _______________________________________
City, state, ZIP _______________________________________
Birth date ___ /___ / _______
Phone (____) ____ - _______
Birth date ___ /___ / _______
Phone (____) ____ - _______
* Must be a member of the organization and be present for the entire event.
Step 4: Tell us about the gambling equipment used in your charitable games events
4
Does your organization own any of the gambling equipment you will use in your charitable games event? _____ yes _____ no
If “yes,” you must complete Form RCG-9, Application or Annual Report for Charitable Games Equipment Ownership Permit. There is a
onetime $50 fee due with the initial permit application. Form RCG-9 must be completed and sent to us every year.
5
Provide the following information for all persons or organizations from whom you will purchase, lease, rent, or borrow any gambling equipment
used in your charitable games events. Attach additional sheets if needed.
Name ______________________________________________
Name ______________________________________________
Street address _______________________________________
Street address _______________________________________
City, state, ZIP _______________________________________
City, state, ZIP _______________________________________
Supplier’s license number ______________________________
Supplier’s license number ______________________________
or if borrowed, charitable games license no. ________________
or if borrowed, charitable games license no. ________________
RCG-1 front (R-01/14)
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