Fillable Form 490601: BINGO ORGANIZATION CHANGE FORM (Kansas Department of Revenue)

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Form 490601: BINGO ORGANIZATION CHANGE FORM (Kansas Department of Revenue)

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The Form 490601: BINGO ORGANIZATION CHANGE FORM (Kansas Department of Revenue) form is 2 pages long and contains:

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  • 30 check-boxes
  • 64 other fields

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File type: PDF

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KANSAS DEPARTMENT OF REVENUE
BINGO ORGANIZATION CHANGE FORM
Organization’s Name
Organization’s Mailing Address
Organization’s License Number
Section 1: Changing the Day or Date of a Game of Bingo
Change from (day or date) _________________________ to (day or date) ________________________
* This is a permanent change. Eective date of this change (mm/dd/yyyy): _________________________
* This date and time is a temporary change. How long will this change be in eect?
* One-time change * The month of ____________________ * From _____________ to _____________
* Other ___________________________________________________________________________________
Section 2: Changing the Time of a Game of Bingo
Change from (indicate A.M. or P.M.) ____________ to (A.M. or P.M.) _____________ on (day or date) _______________
* This is a permanent change. Eective date of this change (mm/dd/yyyy): __________________________
* This date and time is a temporary change. How long will this change be in eect?
* One-time change * The month of ____________________ * From _____________ to _____________
* Other ___________________________________________________________________________________
Section 3: Changing the Location Address of a Game of Bingo
Change the location address from ______________________________________________________________________
to ______________________________________________________________________
If this is a leased premises, provide the Bingo Premises Registration Certicate Number: __________________________
* This is a permanent change. Eective date of this change (mm/dd/yyyy): ______________________
* This date and time is a temporary change. How long will this change be in eect?
* One-time change * The month of ___________________ * From _____________ to _____________
* Other ___________________________________________________________________________________
Vending machine(s) have been: * Added * Removed Eective Date: _______________
If vending machines are added or removed, enter the number of vending machines: ___________
BI-10 (Rev. 8-19)
490601
Page 1
Section 4: Changes to ocers, directors, ocials, volunteers or employees:
Check the appropriate box: * Add * Remove
Name: ________________________________________________________ Title: ____________________________
Daytime Phone: __________________ Social Security Number: __________________Date of Birth: _______________
Date Assumed Oce: ___________________ Email Address: _____________________________________________
Mailing Address: _________________________________________________________________________________
Street City State Zip
Check the appropriate box:
* Add * Remove
Name: ________________________________________________________ Title: ____________________________
Daytime Phone: __________________ Social Security Number: __________________Date of Birth: _______________
Date Assumed Oce: ___________________ Email Address: _____________________________________________
Mailing Address: _________________________________________________________________________________
Street City State Zip
Check the appropriate box:
* Add * Remove
Name: ________________________________________________________ Title: ____________________________
Daytime Phone: __________________ Social Security Number: __________________Date of Birth: _______________
Date Assumed Oce: ___________________ Email Address: _____________________________________________
Mailing Address: _________________________________________________________________________________
Street City State Zip
Check the appropriate box: * Add * Remove
Name: ________________________________________________________ Title: ____________________________
Daytime Phone: ___________________ Social Security Number: _________________ Date of Birth: _______________
Date Assumed Oce: ___________________ Email Address: _____________________________________________
Mailing Address: _________________________________________________________________________________
Street City State Zip
Has the person(s) being added 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 * Yes
If yes, list the name of each such person and particulars of conviction or bond forfeiture on a separate page and enclose with this form.
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 such act.
_________________________________________________________________________________________________
Signature Title
490602
_________________________________________________________________________________________________
Printed Name Daytime Phone Date Signed
This form must be signed by an authorized contact as listed on the most recent application or Power of Attorney Form (DO-10).
Page 2
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INSTRUCTIONS
To conduct bingo games on a date, time or a dierent location than is currently on le, the bingo licensee must submit written
notice of the change(s) to the Oce of Charitable Gaming at least three days prior to the eective date of the change.
• Enter the Organization’s name, mailing address, and license number as listed on your license.
• If there are no changes being made to any of the following sections, leave those sections blank.
• Complete Section 1 if the day or date of a bingo game is being changed. Complete all elds and indicate if this is a
permanent or temporary change.
• Complete Section 2 if the time of a bingo game is being changed. Complete all elds and indicate if this is a permanent
or temporary change.
• Complete Section 3 if the location address is being changed. Complete all elds that apply and indicate if this is
a permanent or temporary change. If there is a change in vending machines, check the appropriate box, enter the
eective date of this change, and enter the number of vending machines being added or removed.
• Complete Section 4 if there are changes to ocers, directors, ocials, volunteers or employees that need to be made.
Please check the appropriate box (Add or Remove), enter the name, title, daytime phone number, social security
number, date of birth, date assumed oce, email address, and mailing address. If more changes need to be made to
personnel than space allows, put all of the pertinent information for the additional changes on a separate sheet of paper
and include that paper with this form.
• Answer yes or no as to whether the person(s) being added have been convicted of a felony. If one of them has, put all
of the pertinent information about the conviction, including the name of the person(s) and the particulars on a separate
piece of paper and include that paper with the application.
• Complete the signature portion. REMINDER: Bingo Organization Change Form (BI-10) will only be accepted if signed
by an authorized contact for the organization. Authorized contacts include the presiding ocer and/or contact person
listed on the organization’s most recent application.
GENERAL INFORMATION
• If you have questions call 785-368-8222; email kdor_bingo@ks.gov; or visit our website at: https://ksrevenue.org/
bustaxypes.html.
• This form MUST be received by the Department of Revenue at least three days prior to the eective date of the change.
• This form can be faxed to 785-296-4993 or emailed to kdor_bingo@ks.gov.
• Complete this form and mail or hand deliver to:
Kansas Department of Revenue
Charitable Gaming
120 SE 10th Ave
PO Box 750680
Topeka KS 66625-0680
Page 3
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Form 490601: BINGO ORGANIZATION CHANGE FORM (Kansas Department of Revenue)

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Completed 24 August 2020

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