Form L-2058 - Application For Bingo License Non Profit Organization (Page 4 of 4) in pdf

Form L-2058 - Application For Bingo License Non Profit Organization Page 4

20. A COPY OF THE FOLLOWING DOCUMENTS MUST BE ATTACHED TO THIS APPLICATION.

a. Membership list of past 12 months including address(s) and phone number(s).

b. Financial statements showing gross income and expenses for current and previous 3 years.

c. Minutes of meeting of the past 24 months.

d. List of charitable activities for the past three years.

e. List of assets owned by organization.

21. Provide the following information for each person who will work at the proposed bingo games and who will receive

compensation for the work. Under Section 12-21-4060 of Bingo Tax Act, a person who has been convicted within the

last twenty years of violating a state or federal criminal statute relating to gaming or gambling, or who had been

convicted of any other crime that has a sentence of two or more years, or where applicable, whose promoters license

has been revoked by the department is not permitted to manage or conduct a game or assist in any manner with the

bingo operation.

Work to be

Ever

DOB

Name

Home Address

S.S. #

Phone #

Performed

Convicted?

Attach additional sheet, if necessary.

AFFIDAVIT

STATE OF SOUTH CAROLINA

County of _________________________________

of the

(Please Print)

(Title)

_________________________________________________________ nonprofit organization swear (or affirm) that the

information contained herein and on the attached sheets is, to the best of my knowledge and belief, true and correct, that

the game of Bingo will be conducted as outlined in Sections 12-21-3910 and 12-21-3920 of the S.C. Code, and that the

nonprofit organization will advise the Department, in writing, within 30 days of any changes in the information supplied on

this application. Furthermore, I swear (or affirm) under penalties of perjury that this organization is not primarily engaged

in the business of conducting Bingo.

Sworn to and subscribed before me this

_____________________ day of _____________ , 20 ________

________________________________

Signature

____________________________________________________

________________________________

(Notary Public for S.C.)

If partnership, all partners must sign.

41374026

Form L-2058 - Application For Bingo License Non Profit Organization Page 4