Fillable Form 492401: BINGO PREMISES REGISTRATION APPLICATION (Kansas Department of Revenue)

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Form 492401: BINGO PREMISES REGISTRATION APPLICATION (Kansas Department of Revenue)

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KANSAS DEPARTMENT OF REVENUE
BINGO PREMISES REGISTRATION 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.
Registration for Fiscal Year (Registration will be valid July 1, or date of issuance, through June 30.)_________________
*
*
________________________
_____________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________
____________________________________________________________________________________________________
* * *
______________________________________________________
Select One:
New Registration Application
Renewal Registration Application Registration Number:
Business Information (As listed with IRS):
1. Federal Employer Identication Number (FEIN):
2. Name of Business:
3. Phone Number Associated with the FEIN:
4. Mailing Address:
Street City State Zip
5. Type of Business Entity: Sole Proprietorship Partnership Corporation
If this is a corporation, provide the state and date of incorporation:
State Date (mm/dd/yyyy)
Lessor’s Information (DBA):
6. Date you wish license to become active (mm/dd/yyyy):
______________________________________________________________
________________________________________________________________________________________
7. Lessor’s Name (DBA name):
* Check this box if the Daytime Phone Number is the same as what is listed on line 3.
8. Lessor’s Daytime Phone Number: ___________________________________________________________________________________
* *
___________________________________________________________________
* *
9. Do you operate a concession stand at this location? No Yes
If yes, provide your sales tax registration number:
10. Has any owner, lessor, partner or employee previously held a registration? No Yes
If yes, provide the following:
Federal Employer Identication Number: Registration Number:
Business Name:
____________________________ ________________________
___________________________________________________________________________________________________
11. Has any owner, lessor partner or employee had a registration denied, rejected, revoked or suspended? No Yes
If yes, provide the following:
Federal Employer Identication Number: Registration Number:
Business Name:
Date and reason:
* *
____________________________ _________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________________________________
12. Physical Address:
Street City State Zip
__________________________________________________________________________________________________
* Check this box if the Lessor’s Mailing Address is the same as the physical address.
13. Lessor’s Mailing Address:
Street City State Zi
p
__________________________________________________________________________________________
492401
BI-148 (Rev. 8-19) Page 1
Contact Person Information:
Name: _________________________________________________________________ _____________________________________________
_______________________________________ _____________________________________________________
Title:
Phone Number: Email Address:
Bingo Games:
List the bingo license number, month and/or day and times for each organization that is or will be leasing this premises from you for the
conduct of bingo games.
License Number Weekly Games Monthly Games
Day game is played: Start Time: Day game is played: Start Time:
______________________ _____________________ _____________ ______________________ _____________
______________________ _____________________ _____________ ______________________ _____________
______________________ _____________________ _____________ ______________________ _____________
______________________ _____________________ _____________ ______________________ _____________
______________________ _____________________ _____________ ______________________ _____________
______________________ _____________________ _____________ ______________________ _____________
Owner/Ocer Information:
A) Name: _______________________________________________________________________ ____________________________________
________________________________________________ ___________________________________
_____________________________________________ ___________________________________
________________________________________________________________________________________________________
Title:
Date of Birth: Social Security Number:
Daytime Phone: First Date of Ownership:
Home Address:
Street City State Zip
B) Name:
_______________________________________________________________________ ____________________________________
________________________________________________ ___________________________________
_____________________________________________ ___________________________________
________________________________________________________________________________________________________
Title:
Date of Birth: Social Security Number:
Daytime Phone: First Date of Ownership:
Home Address:
Street City State Zip
C) Name: _______________________________________________________________________ ____________________________________
________________________________________________ ___________________________________
_____________________________________________ ___________________________________
________________________________________________________________________________________________________
Title:
Date of Birth: Social Security Number:
Daytime Phone: First Date of Ownership:
Home Address:
Street City State Zip
D) Name: _______________________________________________________________________ ____________________________________
________________________________________________ ___________________________________
_____________________________________________ ___________________________________
________________________________________________________________________________________________________
Title:
Date of Birth: Social Security Number:
Daytime Phone: First Date of Ownership:
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 this 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.
492402
Page 2
Responsible Party Information (Must have a Kansas address):
Name: ____________________________________________________________________ _______________________________
________________________________________________________________________________________________________
Home Phone:
Home Address:
Street City State Zip
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
NOTE: If additional space is needed, enter necessary information on a separate page and attach it to this application.
Has this 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.
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.
_____________________________________________________ ________________________________
_____________________________________________________
Owner/Presiding Ocer Signature Date
Owner/Presiding Ocer Printed Name
492403
Page 3
GENERAL INFORMATION
Filing Information: To save postage this application and the payment of a fees due the Kansas Department of Revenue this application
can be led and fees paid electronically at: https://www.kdor.ks.gov/Apps/kcsc/login 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
REGISTRATION/RENEWAL PROCESS:
The following steps are required to register a premises:
•
•
•
Complete a Bingo Premises Application (BI-148).
Pay a $100 application fee by check or money order
Allow 14 business days for your application to be processed and
your registration certicate to be mailed to you.
Upon approval, each leased
bingo premises
is assigned a bingo registration number and issued a Kansas Bingo Premises registration
certicate. The registration certicate must be displayed in plain view at the premises. The usual practice is to display the certicate in the
area where the licensed organization is selling bingo cards.
Registration certicates expire on June 30 of each year and must be renewed annually.
EXEMPTION FROM REGISTRATION OF PREMISES:
A premises may be exempted from registration by the administrator if the following conditions exist:
•
•
There is no charge made for the use of the premises or the charge is a xed nominal amount intended to cover only the premises
owner’s actual costs for utilities and maintenance for the time
period it is used for bingo, or
The organization is the full-time, exclusive tenant of the premises; the rent is paid monthly or annually; the conduct of bingo games
is
only
a relatively small part of
the organization’s activities on the premises; and the amount of rent paid is not based on whether
bingo
games are conducted on the premises or the amount of the receip
ts from conducting bingo games.
The circumstances must be documented in writing, including any agreement between the premises owner and the licensed organization,
and submitted to the administrator for a decision.
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.
INSTRUCTIONS
LICENSE YEAR: Premises registrations 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 Registration Application” or “Renewal Registration Application”. If the “Renewal Registration
Application” is selected, enter the bingo registration number. All questions must be completed. The Department reserves the right to
request additional information or deny the application.The lessor must inform the department within 30 days of any changes in the
information supplied in its most recent application led with the department. The premises registration will expire June 30.
BUSINESS INFORMATION:
Line 1 - Enter the Busineses Federal Employer Identication Number (FEIN).
Line 2 - Enter the Business Name as it appears with the IRS.
Line 3 - Enter a daytime phone number.
Line 4 - Enter the business mailing address.
Line 5 - Select the business entity. If Corporation is selected, enter the state incorporated and incorporation date.
LESSOR’S INFORMATION:
Line 6 - Enter the date that you want the license to become active.
Line 7 - Enter the Lessor’s name.
Line 8 - Enter the Lessor’s daytime phone number. If the lessor’s daytime phone is the same as line 3, check the box to indicate this.
Line 9 - If you will be operating a concession stand check “Yes” and enter the Kansas sales tax number, otherwise check “No”.
Line 10 - If any owner, partner or employee had previously held a license check “Yes” and enter the FEIN, License Number and Business
Name, otherwise check “No”.
Line 11 - If any owner, lessor, partner or employe has had a license denied, rejected, revoked or suspended check “Yes” and enter the
License Number, FEIN, Business Name, Date and Reason, otherwise check “No”.
Line 12 - Enter the address for the location where the bingo games will take place.
Line 13 - Enter the address where letters and notices can be sent.
CONTACT PERSON INFORMATION: Enter the name, daytime phone number and email address of the person that can be contacted
with questions regarding your account.
BINGO GAMES: Enter the license number, day game is played and start time under the appropriate column for each organization that is
or will be leasing this premises from you for the conduct of bingo games. Attach additional pages if more space is needed.
OWNER/OFFICER INFORMATION: Enter the name, title, date of birth, social security number, daytime phone number, initial date of
employment and 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 occured. Attach additional pages if needed for listing all of the owners and ocers.
RESPONSIBLE PARTY INFORMATION: Enter the full name, home phone number and address for the Responsible Party.
EMPLOYEE INFORMATION: List the name, title, address, social secutity number, date of birth, daytime and phone number of each
employee, including salespeople operating as independent contractors or subcontractors. 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 occured. Attach
additional pages if more space is needed.
OWNER/PRESIDING OFFICER SIGNATURE: The signature of either an owner or presiding ocer is required before this application
can be approved.
REQUIRED DOCUMENTS: The below documents are required and must be attached to this application.
Sample copy of your lease agreement that you will be using for this scal year.•
The Department reserves the right to request additional documents, such as your Articles of Incorporation.
Page 4
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Form 492401: BINGO PREMISES REGISTRATION APPLICATION (Kansas Department of Revenue)

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Completed 24 August 2020

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