KANSAS DEPARTMENT OF REVENUE
REPORT OF BINGO TRUST BANK ACCOUNT
AND CONSENT TO EXAMINE AND AUDIT ACCOUNT
In compliance with K.S.A. 75-5179(j), ,
Name of Organization
__________________________________________________________________
Bingo License No. ________________, hereby notifies the Administrator of Charitable Gaming of the bingo
trust bank account established by this organization on ________________________, 20______:
__________________________________________________________________________________________________________
Account Name Account Number
__________________________________________________________________________________________________________
Name of Bank or Savings and Loan
__________________________________________________________________________________________________________
Address of Bank or Savings and Loan
On behalf of the above-named organization, I hereby authorize the above-named bank or savings
and loan association to allow at any reasonable time any agent or investigator of the Kansas
Secretary of Revenue to examine and audit the records of the aforementioned trust account.
__________________________________________________________________________________________________________
Printed Name of Person Authorized to Make Withdrawals Date
___________________________________________________________________________________
Signature of Person authorized to make Withdrawals
Instructions
K.S.A. 79-5179(j) states:
Every licensee who has gross receipts of $1,000 or more received from participation in games, admission
fees or charges and from other sources directly related to the operation or conduct of any games of
bingo in any calendar month shall maintain a bingo trust bank account into which all such receipts
are deposited daily and from which all payments are made relating to the management, operation or
conduct of any games of bingo.
If your organization is required by the above statute to maintain a bingo trust account, complete the
above form and send to:
Kansas Department of Revenue
Division of Taxation
120 SE 10th Ave
PO Box 750680
Topeka KS 66625-0680
This form can be faxed to 785-296-4993. If you have questions call 785-368-8222 or go to our website
at: https://www.ksrevenue.org/bustaxtypesbingo.html.
BI-56 (Rev. 8-19)
491318
