Fillable Form 492501: BINGO DISTRIBUTOR REGISTRATION APPLICATION (Kansas Department of Revenue)

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Form 492501: BINGO DISTRIBUTOR REGISTRATION APPLICATION (Kansas Department of Revenue)

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KANSAS DEPARTMENT OF REVENUE
BINGO DISTRIBUTOR 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. Business’s Federal Employer Identication Number (FEIN): __________________________________________________________
2. Business Name: ____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
3. Business Phone:
4. Mailing Address:
Street City State Zip
5. Business Type: LLC Partnership Sole Proprietorship Corporation* * * *
If this is a corporation, provide the state and date of incorporation:
State Date (mm/dd/yyyy)
______________________________________________________
Distributor Information (DBA):
6. Registration start date (mm/dd/yyyy): ________________________________
* Check this box if the DBA (Distributor) Name is the same as what is listed on line 2.
7. DBA (Distributor) Name:_____________________________________________________________________________________________
* Check this box if the Business Phone is the same as what is listed on line 3.
8. Business Phone: ____________________________________________________
9. Has anyone that is listed as an owner, partner or employee previously held a license? No Yes* *
If yes, provide the FEIN, business name, organization name, or license or registration number.
FEIN:______________________________ _______________________________________________________________
____________________________________
Business Name:
License or Registration Number:
10. Has any owner, partner or employee had a license or registration denied, rejected, or suspended? No Yes* *
If yes, provide the FEIN, business name, organization name, or license or registration number, as well as the date and
reason for denial, rejection or suspension.
FEIN:
_____________________________ Business Name: _______________________________________________________________
License or Registration Number: ___________________________________________________________________________________
Date of Denial, Rejection or Suspension (mm/dd/yyyy):___________________________________
Reason for Denial, Rejection or Suspension: _______________________________________________________________________
___________________________________________________________________________________________________________________
* Check this box if the DBA Physical Address is the same as the mailing address.
11. DBA Physical Address:
Street City State Zip
_____________________________________________________________________________________________
* Check this box if the DBA Mailing Address is the same as listed on line 4.
12. DBA Mailing Address:
Street City State Zip
______________________________________________________________________________________________
13. Will you be oering instant bingo ticket vending machines to Bingo Organizations? Yes No* *
492501
BI-158 (Rev. 8-19) Page 1
Contact Person Information:
Name: __________________________________________________________________________________________________________________
Daytime Phone:________________________________________ Email Address: _________________________________________________
Additional Locations:
A) Site Name: __________________________________________________________________________________________________________
Location Address:
Street City State Zip
___________________________________________________________________________________________________
B) Site Name: __________________________________________________________________________________________________________
Location Address:
Street City State Zip
___________________________________________________________________________________________________
C) Site Name: __________________________________________________________________________________________________________
Location Address:
Street City State Zip
___________________________________________________________________________________________________
NOTE: If additional space is needed, enter necessary information on a separate page and attach it to this application.
Owner Information:
* Check this box if this person is considered the responsible party.
A) Name: _____________________________________________________________________ Title: ___________________________________
Date of Birth: ___________________ Social Security Number:______________________ Daytime Phone: _____________________
Mailing Address:
Street City State Zip
____________________________________________________________________________________________________
* Check this box if this person is considered the responsible party.
B) Name: _____________________________________________________________________ Title: ___________________________________
Date of Birth: ___________________ Social Security Number:______________________ Daytime Phone: _____________________
Mailing Address:
Street City State Zip
____________________________________________________________________________________________________
* Check this box if this person is considered the responsible party.
C) Name: _____________________________________________________________________ Title: ___________________________________
Date of Birth: ___________________ Social Security Number:______________________ Daytime Phone: _____________________
Mailing 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 owner(s), within ve years prior to this registration, been convicted of or pleaded guilty or pleaded no contest to any felony or illegal gambling
violation in this or any other state? No Yes* *
If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.
Record Keeper Information: (The person who is responsible for maintaining record of sales.)
Name: _________________________________________________________________________ Title: ___________________________________
Daytime Phone:_________________________________ Email Address:________________________________________________________
Mailing Address:
Street City State Zip
________________________________________________________________________________________________________
492502
Page 2
Employee Information:
A) Name: _______________________________________________________ Title: ____________________________
Date of Birth: _________________________________ Social Security Number: ______________________________
Home Phone: ________________________________ Date Employment Started: ____________________________
Home Address: _________________________________________________________________________________
Street City State Zip
B) Name: _______________________________________________________ Title: ____________________________
Date of Birth: _________________________________ Social Security Number: ______________________________
Home Phone: ________________________________ Date Employment Started: ____________________________
Home Address:
Street City State Zip
_________________________________________________________________________________
C) Name: _______________________________________________________ Title: ____________________________
Date of Birth: _________________________________ Social Security Number: ______________________________
Home Phone: ________________________________ Date Employment Started: ____________________________
Home Address:
Street City State Zip
_________________________________________________________________________________
D) Name: _______________________________________________________ Title: ____________________________
Date of Birth: _________________________________ Social Security Number: ______________________________
Home Phone: ________________________________ Date Employment Started: ____________________________
Home Address:
Street City State Zip
_________________________________________________________________________________
E) Name: _______________________________________________________ Title: ____________________________
Date of Birth: _________________________________ Social Security Number: ______________________________
Home Phone: ________________________________ Date Employment Started: ____________________________
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 employee(s), within ve years prior to this registration, been convicted of or pleaded guilty or pleaded no contest to any felony or illegal
gambling violation in this or any other state? No Yes* *
If yes, provide the name of each person and the particulars on a separate page and enclose it with this application.
VERIFICATION OF BINGO DISTRIBUTOR – MUST BE SIGNED
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
_________________________________________________________________________________________________________________________
Owner/Presiding Ocer Printed Name Date
492503
Page 3
Page 4
GENERAL INFORMATION
Filing 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, fees and any documentation to:
Kansas Department of Revenue
Charitable Gaming
120 SE 10th Ave
PO Box 750680
Topeka KS 66625-0680
REGISTRATION/RENEWAL PROCESS
Registration Requirements: A business is required to register as a bingo distributor with the Kansas Department of Revenue if it
sells or distributes disposable paper bingo cards (faces) , instant bingo tickets (pull-tabs), handheld monitors, or vending machines to
organizations in Kansas which are licensed to conduct bingo games.
The following steps are required to register as a bingo supplies distributor:
•
•
•
•
Complete an Application for Initial Registration of Bingo Distributor.
Pay an application fee of $500 by check or money order.
For all new applications, pay a tax bond of $1,000 by separate 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 distributor will be assigned a registration number and issued a Kansas Bingo Distributor Registration Certicate.
Distributor Registration Certicate: Each distributor registration certicate shall expire at midnight on June 30 following its date of
issuance.
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
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 Bingo Distributor must inform the department within 30 days of any changes
in the information supplied in its most recent application led with the department. The bingo Distributor registration will expire June 30.
BUSINESS INFORMATION
Line 1. Enter the 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 Business Name.
Line 3. Enter the Daytime Phone Number associated with this FEIN.
Line 4. Enter the mailling address of the business.
Line 5. Select the Business Entity. If Corporation is selected enter the state incorporated and incorporation date.
DISTRIBUTOR INFORMATION
Line 6. Enter the date you want your license to become eective. This date cannot be in the past.You must have an active license before
operating as a Bingo Distributor.
Line 7. Enter the Distributor’s DBA name if applicable.
Line 8. Enter the Business Daytime Phone Number.
Line 9. 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 10. If any owner, lessor, partner or employee has had a license denied, rejected, or suspended check “Yes” and enter the FEIN,
License Number, Business Name, Date and Reason, otherwise check “No”.
Line 11. Enter the Physical Location Address.
Line 12. Enter the Distributor’s DBA Mailing Address.
Line 13. If the distributor will be oering instant bingo ticket vending machines to bingo organizations check “Yes”, otherwise check “No”.
CONTACT PERSON INFORMATION: Enter the full name, daytime phone and email address for the contact person.
ADDITIONAL LOCATIONS: Other than the physical address already provided, list names and addresses of all oces, manufacturing
and storage locations where your bingo records of sales to Kansas licensees are kept and all locations which will be involved in distributing
disposable paper bingo cards or instant bingo tickets. Post oce boxes are not allowed. If the address cannot be veried, your application
may not be approved. Attach additional pages if needed for listing all of the additional locations.
OWNER INFORMATION: Check the box if the person is considered the responsible party. Enter the full name, title, date of birth, social
security number, home phone number and mailing address of all owners, partners, corporate ocers or directors. If the answer to
convictions is “Yes”, provide information regarding the conviction along with the date convicted on a separate sheet.
RECORD KEEPER INFORMATION: Enter the full name, title, daytime phone number, email address and mailing address of the person
who will maintain records of the sales of disposable paper cards and instant bingo tickets in Kansas.
EMPLOYEE INFORMATION: Enter the full name, title, date of birth, social security number, home phone number, date employment
started, and home address. If the answer to convictions is “Yes”, provide information regarding the conviction along with the date convicted.
Attach additional pages if more space is needed.
SIGNATURE: A signature of the owner or presiding ocer, date and printed name is required.
The Department reserves the right to request additional documents, such as your Articles of Incorporation.
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Form 492501: BINGO DISTRIBUTOR REGISTRATION APPLICATION (Kansas Department of Revenue)

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Completed 24 August 2020

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