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 DEPARTMENT OF REVENUE
BINGO ORGANIZATION LICENSE APPLICATION
IMPORTANT: 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 Year (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):
1.
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. Type of Nonprot: Charitable Educational Fraternal Religious Veteran* * * * *
6. Does this organization have IRS approved non-prot status? Yes 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
_____________________________________________________________________________________________________________________________________
11. Mailing Address:
Street City State Zip
______________________________________________________________________________________________________________________________________
12. Does the organization have by-laws? Yes No Pending* * *
13. Has your organization been in existence for 18 months or longer? Yes No* *
14. Is membership in your organization denied to any person for reasons of race, color or physical handicap? Yes No* *
15. Has your organization ever been issued any type of Charitable Gaming License? No Yes* *
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 Yes* *
____________________________________________
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 Yes* *
If yes, enter the number of vending machines: ________________
BI-60 (Rev. 8-19)
491401
Page 1
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 Yes* *
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 Yes* *
If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.
Contact Person Information:
Name: _____________________________________________________________________________________________________________________________________________________
Daytime Phone:_____________________________________________________ Email Address: __________________________________________________________________
Bingo Play Information:
Physical Address Where Games Will Be Played:
Street
City State County Zip
___________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
Is your organization registered to collect and remit Kansas sales tax on this location? Yes No
* *
If yes, enter your KS Sales Tax Account Number:
_____________________________________________________________
Is this a leased or rented premises? No Yes* * 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 Time: 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* * __________________________ _______________ ___________________________ ________________
491402
Page 2
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
__________________________________________________________________________________________________________________________________________
B) Name:
_________________________________________________________________________________________ Date of Membership: _________________________________
Date of Birth: _______________________ Social Security Number: ___________________________ Daytime Phone: ____________________________________
Home Address:
Street City State Zip
__________________________________________________________________________________________________________________________________________
C) Name:
________________________________________________________________________________________ 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 Yes* *
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: Title:
Date of Birth: Social Security Number:
Daytime Phone: Date Assumed Oce:
Home Address:
Street City State Zip
B) Name: Title:
Date of Birth: Social Security Number:
Daytime Phone: Date Assumed Oce:
Home Address:
Street City State Zip
C) Name: Title:
Date of Birth: Social Security Number:
Daytime Phone: Date Assumed Oce:
Home Address:
Street City State Zip
D) Name: Title:
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 Yes* *
If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.
491403
Page 3
Employee Information:
A) Name: Title:
Date of Birth: Social Security Number:
Daytime Phone: Initial Date of Employment:
Home Address:
Street City State Zip
B) Name: Title:
Date of Birth: Social Security Number:
Daytime Phone: Initial Date of Employment:
Home Address:
Street City State Zip
C) Name: Title:
Date of Birth: Social Security Number:
Daytime Phone: Initial Date of Employment:
Home Address:
Street City State Zip
D) Name: Title:
Date of Birth: Social Security Number:
Daytime Phone: Initial Date of Employment:
Home Address:
Street City State Zip
E) Name: Title:
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
such act.
Presiding Ocer Signature Secretary Signature
Presiding Ocer Printed Name Date Secretary Printed Name Date
491404
Page 4
GENERAL INFORMATION
To 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
Topeka KS 66625-0680
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
To 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.
APPLICATION 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
June 30.
NON-PROFIT ORGANIZATION INFORMATION
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”.
Page 5
Page 6
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Form 491401: BINGO ORGANIZATION LICENSE APPLICATION (Kansas Department of Revenue)

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Completed 24 August 2020

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