Fillable Form 491618: RAFFLE RETURN AND RECONCILIATION (Kansas Department of Revenue)

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Form 491618: RAFFLE RETURN AND RECONCILIATION (Kansas Department of Revenue)

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RAFFLE RETURN AND RECONCILIATION
(Due by July 25th)
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.
Organization’s Name
Organization’s Mailing Address
Organization’s License Number
Reporting Year (yyyy)
KANSAS DEPARTMENT OF REVENUE
*Check here if this is a new mailing address.
Check One:
Original Return and Reconciliation
Amended Return and Reconciliation
1. Total gross receipts for all rae ticket sales for the reporting period ......................................................$ _____________________
2. License fee based on the scal year gross receipts...............................................................................$ _____________________
3. Rae license fee remitted with the application ......................................................................................$ _____________________
4. Credit Amount (See instructions)............................................................................................................$ _____________________
5. Balance Due (See instructions).............................................................................................................. $ _____________________
If there is a credit amount on line 4, check one of the following:
Apply credit to the next scal year license fee. Refund the amount.* *
Names and address for all winners of prizes valued at $1,199 or more:
Name: ____________________________________________________________________________________________________
Mailing Address:
Street City State Zip
____________________________________________________________________________________________
Name: ____________________________________________________________________________________________________
Mailing Address:
Street City State Zip
____________________________________________________________________________________________
Name: ____________________________________________________________________________________________________
Mailing Address:
Street City State Zip
____________________________________________________________________________________________
Name: ____________________________________________________________________________________________________
Mailing Address:
Street City State Zip
____________________________________________________________________________________________
Name: ____________________________________________________________________________________________________
Mailing Address:
Street City State Zip
____________________________________________________________________________________________
I certify this is a true, correct and complete return.
_________________________________________________________________________________________________________________________
Signature Title Date
___________________________________________________________________________________________________________________________
Printed Name Daytime Phone
*
*
Page 1BI-75 (Rev. 8-19)
491618
INSTRUCTIONS
Report Type: Select the type of report you are ling: Original or Amended.
Organization Information: Enter the organization’s name, mailing address, license number and reporting
year.
Line 1. Enter the organization’s total gross receipts for all rae ticket sales during the scal year in
which you are reporting.
Line 2. Enter the appropriate license fee amount based on the scal year gross receipts below:
Fiscal Year Gross Receipts Amount License Fee Amount
$0 to $25,000 $0
More than $25,000 but do not exceed $50,000 $25.00
Exceeds $50,000 but do not exceed $75,000 $50.00
Exceeds $75,000 but do not exceed $100,000 $75.00
Exceeds $100,000 $100.00
Line 3. Enter the license fee that was remitted with the application.
Line 4 If Line 3 is greater than Line 2, enter the dierence on Line 4 as this will be a credit
Line 5. If Line 2 is greater than Line 3, enter the amount on Line 5. Remit the balance due to the
address below or le and pay online.
• If there is a credit amount on line 4, check one of the options “Apply credit to the next scal year
license fee.” or “Refund the amount.”.
• Enter the names and addresses for all winners of prizes valued at $1,199 or more. If more space
is needed, enter all necessary information on a separate sheet and attach it to this application.
GENERAL INFORMATION
• File and pay electronically by going to:
https://www.kdor.ks.gov/Apps/kcsc.
• This form can be faxed to 785-296-4993 or emailed to kdor_bingo@ks.gov.
• If you have questions call 785-368-8222.
• For additional information, visit our website at: https://www.ksrevenue.org/bustaxtypesbingo.html.
• When sending a check or money order, write your license number on your check or money order and
make payable to Charitable Gaming. Send your return and payment to:
Kansas Department of Revenue
Charitable Gaming
120 SE 10th Ave
PO Box
750680
Topeka KS 666
25-0680
Page 2
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Form 491618: RAFFLE RETURN AND RECONCILIATION (Kansas Department of Revenue)

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Completed 24 August 2020

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