Fillable Form 491401: BINGO ORGANIZATION LICENSE APPLICATION (Kansas Department of Revenue)

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Form 491401: BINGO ORGANIZATION LICENSE APPLICATION (Kansas Department of Revenue)

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KANSAS DEP ARTMENT OF REVENUE BINGO ORGANIZA TION LICENSE APPLICA TION IMPORT ANT : Save time and paper by ling electronically . See the electronic le and pay options available by visiting our website at https://www .kdor . ks.gov/apps/kcsc. License for Fiscal Y ear (License wIll be valid July 1, or date of issuance, through June 30) ______________________ Select One: New License Application Renewal License Application Bingo License Number: _______________________________________ Nonprot Organization Information (As listed with IRS):

Nonprot Organization’s Federal Employer Identication Number (FEIN): _________________________________

2. Nonprot Organization’s Name: ______________________________________________________________________________________________________________________

3. Nonprot Organization’s Daytime Phone Number: ________________________________ 4. Mailing Address: Street City State Zip 5. T ype of Nonprot: Charitable Educational Fraternal Religious V eteran * * * * * 6. Does this organization have IRS approved non-prot status? Y es No Pending * * *

Bingo Organization Information (DBA): * Check this box if the phone number and mailing address are the same as above.

7. Date you want license to become active (mm/dd/yyyy): _________________________________________________________________________________________

8. Bingo Organization’s Name: ________________________________________________________________________________________________________________________

9. Bingo Organization’s Daytime Phone Number: ___________________________________________________________________________________________________

10. Physical Address: Street City State County Zip 1 1. Mailing Address: Street City State Zip 12. Does the organization have by-laws? Y es No Pending * * * 13. Has your organization been in existence for 18 months or longer? Y es No * *

14. Is membership in your organization denied to any person for reasons of race, color or physical handicap? Y es No * *

15. Has your organization ever been issued any type of Charitable Gaming License? No Ye s * * If yes, provide the following where applicable: Federal Employer Identication Number: License Number: Business Name: ____________________________________________ ________________________________________

16. Has your organization ever been denied a license or had a license revoked or suspended for any type of Charitable Gaming

L If yes, provide the following where applicable: Federal Employer Identication Number: icense? No Y es * * ____________________________________________ License Number: Business Name: Date and reason for denial, revocation or suspension: ________________________________________ __________________________________________________________________________________________ 17. Will the organization be selling instant bingo tickets from a vending machine? No Ye s * * If yes, enter the number of vending machines: ________________ BI-60 (Rev. 8 -19)

Presiding Ocer Information:

Name: ________________________________________________________________________________________ Date Assumed Oce: __________________________________

Date of Birth: __________________________________________________________ Social Security Number: _____________________________________________________

Daytime Phone: _______________________________________________________ Email Address: ________________________________________________________________

Home Address: Street City State Zip

Has this person been convicted of or pleaded guilty to or pleaded no contest to a violation of gambling laws of the U.S. or have forfeited bond to appear

in court to answer charges for any such violation, or have been convicted or pleaded guilty or pleaded no contest to the violation of any law of this or

any other state which is classied as a felony under the laws of such state? No Ye s * *

If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.

Secretary Information:

Name: ________________________________________________________________________________________ Date Assumed Oce: __________________________________

Date of Birth: __________________________________________________________ Social Security Number: _____________________________________________________

Daytime Phone: _______________________________________________________ Email Address: ________________________________________________________________

Home Address: Street City State Zip

Has this person been convicted of or pleaded guilty to or pleaded no contest to a violation of gambling laws of the U.S. or have forfeited bond to appear

in court to answer charges for any such violation, or have been convicted or pleaded guilty or pleaded no contest to the violation of any law of this or

any other state which is classied as a felony under the laws of such state? No Ye s * *

If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.

Contact Person Information:

Daytime Phone: _____________________________________________________ Email Address: __________________________________________________________________

Bingo Play Information: Physical Address Where Games Will Be Played: City State County Zip ___________________________________________________________________________________________________ Is your organization registered to collect and remit Kansas sales tax on this location? Y es No If yes, enter your KS Sales T ax Account Number: _____________________________________________________________

Is this a leased or rented premises? No Y es * * If yes, provide premises registration number: _________________________________________

Select game type and enter how often the games are played along with start time: Weekly Games Monthly Games Day game is played: Start T ime: Day game is played: Start Time:

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Mini Games Regular Games * * __________________________ _______________ ___________________________ ________________

Nonprot Organization Member Information (Volunteers only):

A) Name: __________________________________________________________________________________________ Date of Membership: _________________________________

Date of Birth: _______________________ Social Security Number: ___________________________ Daytime Phone: ____________________________________

Home Address: Street City State Zip

_________________________________________________________________________________________ Date of Membership: _________________________________

Date of Birth: _______________________ Social Security Number: ___________________________ Daytime Phone: ____________________________________

Home Address: Street City State Zip

________________________________________________________________________________________ Date of Membership: _________________________________

Date of Birth: _______________________ Social Security Number: ___________________________ Daytime Phone: ____________________________________

Home Address: Street City State Zip

NOTE: If additional space is needed, enter necessary information on a separate page and attach it to this application.

Has the person(s) been convicted of or pleaded guilty to or pleaded no contest to a violation of gambling laws of the U.S. or have forfeited bond to

appear in court to answer charges for any such violation, or have been convicted or pleaded guilty or pleaded no contest to the violation of any law of

this or any other state which is classied as a felony under the laws of such state? No Ye s * *

If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.

Ocer Information (Other than President or Secretary): A) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Date Assumed Oce: Home Address: Street City State Zip B) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Date Assumed Oce: Home Address: Street City State Zip C) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Date Assumed Oce: Home Address: Street City State Zip D) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Date Assumed Oce: Home Address: Street City State Zip

NOTE: If additional space is needed, enter necessary information on a separate page and attach it to this application.

Has the person(s) been convicted of or pleaded guilty to or pleaded no contest to a violation of gambling laws of the U.S. or have forfeited bond to

appear in court to answer charges for any such violation, or have been convicted or pleaded guilty or pleaded no contest to the violation of any law of

this or any other state which is classied as a felony under the laws of such state? No Ye s * *

If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.

Employee Information: A) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Initial Date of Employment: Home Address: Street City State Zip B) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Initial Date of Employment: Home Address: Street City State Zip C) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Initial Date of Employment: Home Address: Street City State Zip D) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Initial Date of Employment: Home Address: Street City State Zip E) Name: T itle: Date of Birth: Social Security Number: Daytime Phone: Initial Date of Employment: Home Address: Street City State Zip

NOTE: If additional space is needed, enter necessary information on a separate page and attach it to this application.

Has the person(s) been convicted of or pleaded guilty to or pleaded no contest to a violation of gambling laws of the U.S. or have forfeited bond

to appear in court to answer charges for any such violation, or have been convicted or pleaded guilty or pleaded no contest to the violation of any

law of this or any other state which is classified as a felony under the laws of such state? No Yes

If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.

Under penalties of perjury , I declare that I have examined this application and to the best of my knowledge and belief it is correct

and complete. I will comply with all of the provisions of the Kansas Charitable Gaming Act and the regulations adopted under

Presiding Ocer Signature Secretary Signature Presiding Ocer Printed Name Date Secretary Printed Name Date GENERAL INFORMA TION

T o save postage this application and the payment of fees due to the Kansas Department of Revenue can be completed at:

https:// www .kdor .ks.gov/apps/kcsc , or you can mail your completed application, fee and any documentation to:

Kansas Department of Revenue Charitable Gaming 120 SE 10th Ave PO Box 750680 T opeka KS 666 25-0680 The following steps are required to license a bingo organization. • Complete a Bingo Organization License Application. • Pay a $25 application fee by check or money order .

Upon approval, each bingo organization is assigned a bingo registration number and issued a Kansas Bingo Organization

license certicate.

In order to receive a license by your requested start date, you must apply at least 14 business days in advance, otherwise

we cannot guarantee your application will be approved and certicated mailed by your requested start date.

Contact Information: If you have questions you may call 785-368-8222 or email kdor_bingo@ks.gov . Information can be

faxed to 785-296-4993. LICENSING REQUIREMENTS AND PROCESS T o be eligible for a bingo license, an organization must meet all of the following requirements:

Be a nonprot religious, charitable, fraternal, educational or veterans organization with a tax-exempt ruling from the

Internal Revenue Service. Have been in continuous existence in Kansas for at least 18 months prior to applications

None of the ocers, directors or ocials of the organization, or any person employed on the premises where the bingo

games are to be conducted, has been convicted of a felony or gambling violation in Kansas or any other jurisdiction.

Membership in the organization is open to a person of any race, color or physical handicap.

No person involved in the operation of bingo games for the licensed organization may receive any compensation or prot

from such activity . However , an employee of the organization may assist with bingo.

Each organization may have only one active license at a time. Organizations which are aliated with or subordinate to each

other must have dierent membership requirements.

Bingo licenses expire on June 30 and must be renewed annually . Renewals online are the quickest method of completing

the process. LINE BY LINE INSTRUCTIONS

LICENSE YEAR: Bingo licenses are valid July 1, or date of issuance, through June 30. Enter the scal year for which you

are submitting your application.

APPLICA TION TYPE: Check either “New License Application” or “Renewal License Application”. If “Renewal License

Application” is selected, enter the Bingo License Number . All questions must be completed. The Department reserves the

right to request additional information or deny the application. The organization must inform the department immediately of

any changes in the information supplied in its most recent application led with the department. The bingo license will expire

NON- PROFIT ORGANIZA TION INFORMA TION

Line 1. Enter the Nonprot organization’s FEIN here, or if you do not have an FEIN, you can obtain one from the IRS by

going to www .irs.gov . Line 2. Enter the Nonprot Organization’s name. Line 3. Enter the Nonprot Organization’s daytime phone number . Line 4. Enter the Nonprot Organization’s mailing address. Line 5. Check the appropriate box for the organization’s nonprot type and only check one.

Line 6. Check the appropriate box. If the Nonprot Organization is in process of applying to the IRS, check “Pending”.

LINE BY LINE INSTRUCTIONS CONTINUED BINGO ORGANIZA TION INFORMA TION Line 7 . Enter the date you want your license to become eective Line 8. Enter the Bingo Organization’s name. Line 9. Enter the Bingo Organization’s daytime phone number .

Line 10. Enter the physical location where your organization regularly conducts business which may or may not be the

location of game play . Line 1 1. Enter the mailing address for your organization where we can send notices.

Line 12. Check the appropriate box. If the organization is in the process of creating by-laws check “Pending”.

Line 13. Check “Y es” if your organization has been in existence for 18 months or longer . Otherwise, check “No”.

Line 14. Check “Y es” if your organization denies membership to any person for race, color or physical handicap. Otherwise,

Line 15. Check the appropriate box if your organization has ever been issued any type of Charitable Gaming license. If

“Y es”, enter the Federal Employer Identication Number , License Number and name of the business.

Line 16. Check the appropriate box if your organization has ever been denied, revoked or suspended. If “Y es”, enter the

Federal Employer Identication Number , License Number and name of the business. Then, enter the date and the reason

for denial, revocation or suspension.

Line 17. Check the appropriate box if you will be selling instant bingo tickets from a vending machine.

PRESIDING OFFICER INFORMA TION : Enter the name, date assumed oce, date of birth, social security number , daytime

phone number , email address, and home address. Check the appropriate box regarding legal violations. If this box is

checked yes, send an explanation of the legal action along with the date in which the legal action occurred.

SECRET AR Y INFORMA TION : Enter the name, date assumed oce, date of birth, social security number , daytime phone

number , email address, and home address. Check the appropriate box regarding legal violations. If this box is checked yes,

send an explanation of the legal action along with the date in which the legal action occurred. CONT ACT PERSON INFORMA TION : Enter the full name, daytime phone number and email address.

BINGO PLA Y INFORMA TION : Enter the physical address where the bingo games will be held. Answer the questions

regarding registration information for collecting sales tax and leasing or rental of premises. Select the type of game(s) to be

held, how often the games will be played along with start times. Attach additional pages if more space is needed.

NONPROFIT ORGANIZA TION MEMBER INFORMA TION (V olunteers only) : List members that will be assisting with

bingo. Check the appropriate box regarding legal violations. If this box is checked yes, send an explanation of the legal

action along with the date in which the legal action occurred. Attach additional pages if more space is needed.

OTHER OFFICER INFORMA TION : Other than the Presiding Ocer and Secretary that you have already entered, list all

directors and other principal ocers of your organization, even if they are not directly involved with the conduct of bingo

games. Check the appropriate box regarding legal violations. If this box is checked yes, send an explanation of the legal

action along with the date in which the legal action occurred. Attach additional pages if more space is needed.

EMPLOYEE INFORMA TION : List the full name, title, date of birth, social security number , daytime phone number , initial

date of employment, and home address of each employee. Check the appropriate box regarding legal violations. If this

box is checked yes, send an explanation of the legal action along with the date in which the legal action occurred. Attach

additional pages if more space is needed.

SIGNA TURE REQUIRED : This must be completed with the knowledge and consent of both the Presiding Ocer and the