Form Rcg-10 - Diagram Of Charitable Games Event Playing Areas
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1Illinois Department of Revenue
RCG-10
Diagram of Charitable Games Event Playing Areas
Step 1: Provide information about your charitable games event
1
4
Organization name ____________________________________
Provider license number CP - ____________________________
2
5
Charitable games license number CG - ____________________
Event date ____ / ____ / ________
Month
Day
Year
3
6
Do you own or lease the premises where charitable games will be
Event address _________________________________________
Number and street
played?
_____ own
_____ lease
IL
_____________________________________________________
If you lease the premises specifically for the conduct of charitable
City
State
ZIP
games, attach a signed copy of your lease agreement.
Step 2: Diagram all charitable games event playing areas
Sketch the floor plan of all areas where you will be conducting your
Enter next to each type of game the number of stations you will be
charitable games event. Show and label the location of:
operating during the event depicted in your drawing.
• the bank (where chips will be sold and redeemed),
___ roulette
___ bang
___ chuck-a-luck
• all doorways and entrances into the gaming area, and
___ blackjack
___ beat the dealer
___ keno
• each gaming station.
___ poker
___ big six
___ hold-em poker
___ pull tabs
___ gin rummy
___ merch. wheel
___ craps
___ five card stud
Step 3: Additional charitable games events
If the information provided on this form will carry to multiple charitable games events, please provide the additional dates below. If any piece of
the above information is different, you must complete a separate Form RCG-10 for the additional dates.
____ / ____ / ________
____ / ____ / ________
____ / ____ / ________
____ / ____ / ________
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
____ / ____ / ________
____ / ____ / ________
____ / ____ / ________
Month
Day
Year
Month
Day
Year
Month
Day
Year
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-10 (R-10/13)
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