Form Rcg-2 - List Of Charitable Games Workers Page 2
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1
2Step 3: Identify those who will participate in your events (continued)
CG - ______________
9 _______________________________________________ 15 _______________________________________________
Name
Name
_______________________________________________
_______________________________________________
Number and street
Number and street
_______________________________________________
_______________________________________________
City
State
ZIP
City
State
ZIP
______ - ____ - ________
____ / ____ / ________
______ - ____ - ________
____ / ____ / ________
Social Security number
Date of birth
Social Security number
Date of birth
10 _______________________________________________ 16 _______________________________________________
Name
Name
_______________________________________________
_______________________________________________
Number and street
Number and street
_______________________________________________
_______________________________________________
City
State
ZIP
City
State
ZIP
______ - ____ - ________
____ / ____ / ________
______ - ____ - ________
____ / ____ / ________
Social Security number
Date of birth
Social Security number
Date of birth
11 _______________________________________________ 17 _______________________________________________
Name
Name
_______________________________________________
_______________________________________________
Number and street
Number and street
_______________________________________________
_______________________________________________
City
State
ZIP
City
State
ZIP
______ - ____ - ________
____ / ____ / ________
______ - ____ - ________
____ / ____ / ________
Social Security number
Date of birth
Social Security number
Date of birth
12 _______________________________________________ 18 _______________________________________________
Name
Name
_______________________________________________
_______________________________________________
Number and street
Number and street
_______________________________________________
_______________________________________________
City
State
ZIP
City
State
ZIP
______ - ____ - ________
____ / ____ / ________
______ - ____ - ________
____ / ____ / ________
Social Security number
Date of birth
Social Security number
Date of birth
13 _______________________________________________ 19 _______________________________________________
Name
Name
_______________________________________________
_______________________________________________
Number and street
Number and street
_______________________________________________
_______________________________________________
City
State
ZIP
City
State
ZIP
______ - ____ - ________
____ / ____ / ________
______ - ____ - ________
____ / ____ / ________
Social Security number
Date of birth
Social Security number
Date of birth
14 _______________________________________________ 20 _______________________________________________
Name
Name
_______________________________________________
_______________________________________________
Number and street
Number and street
_______________________________________________
_______________________________________________
City
State
ZIP
City
State
ZIP
______ - ____ - ________
____ / ____ / ________
______ - ____ - ________
____ / ____ / ________
Social Security number
Date of birth
Social Security number
Date of birth
Step 4: Sign below
I hereby certify under penalties of perjury that the individuals listed above are bona fide members, volunteers, or employees of the licensed
organization; that none of them have participated in the management or operation of more than 12 charitable games events within the calendar
year; and that none of them will receive any remuneration or compensation directly or indirectly for participating in the management or operation
of any charitable games event conducted by the licensed organization.
President’s signature _______________________________________
Date ____ / ____ / ____
Secretary’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-2 back (R-01/14)
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