Fillable RAFFLE LICENSE APPLICATION (Kansas Department of Revenue)

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RAFFLE LICENSE APPLICATION (Kansas Department of Revenue)

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RAFFLE 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 Rae License Number:
Non-Prot Organization Information (As listed with IRS):
1. Organization’s Federal Employer Identication Number (FEIN):________________________________________________________
2. Organization’s Name:_________________________________________________________________________________________________
3. Organization’s Daytime Phone Number:_______________________________________________________________________________
4. Mailing Address:
Street City State Zip
____________________________________________________________________________________________________
5. Type of Non-Prot: Charitable Educational Fraternal Religious Veteran
* * * * *
6. Does this organization have proof of IRS approved non-prot status? Yes No Pending
* * *
Select One:
Estimate your gross receipts for rae ticket sales for the scal year July 1 through June 30. Gross receipts of $25,000 or
less per scal year will not require a rae license.
*
Gross receipts exceed $25,000 but do not exceed $50,000 (License Fee: $25)
*
Gross receipts exceed $50,000 but do not exceed $75,000 (License Fee: $50)
*
Gross receipts exceed $75,000 but do not exceed $100,000 (License Fee: $75)
*
Gross receipts exceed $100,000 (License Fee: $100)
Date you want license to become active (mm/dd/yyyy): ________________________
Rae Organization’s Information (DBA): * Check this box if phone number and mailing address are the same as above.
7. Rae Organization Name: __________________________________________________________________________
8. Rae Organization’s Daytime Phone Number: __________________________________________________________
9. Mailing Address: ________________________________________________________________________________
Street City State Zip
10. Does the organization have by-laws? Yes No Pending
* * *
11.
Has your organization been in existence for 18 months or longer?
Yes No
* *
12. Has your organization ever been issued any type of Charitable Gaming license?
No Yes
* *
If yes, provide license information or business information: ________________________________________________
______________________________________________________________________________________________
13. Has your organization ever been denied a license or had a license revoked, or suspended? Yes No
* *
If yes, enter the business and license information, date and reason for denial, revocation or suspension:
______________________________________________________________________________________________
______________________________________________________________________________________________
BI-70 (Rev. 8-19)
KANSAS DEPARTMENT OF REVENUE
________________
*
*
______________________
Page 1
491501
Presiding Ocer Information:
Name: _______________________________________________________________________ ___________________________________Title:
Daytime Phone: Social Security Number: Date of Birth:
__________________________ _______________________ __________________
Date Assumed Oce: Email Address:_____________________________ ______________________________________________________
Mailing 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: Daytime Phone:_______________________________________________________________ _________________________________
Social Security Number: Date of Birth:_______________________________________________________ ____________________________
Date Assumed Oce: Email Address:_____________________________ ______________________________________________________
Mailing 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.
* *
Rae Coordinator Information:
Name: Daytime Phone:_______________________________________________________________ _________________________________
Social Security Number: Date of Birth:_______________________________________________________ ____________________________
Date Assumed Oce: _____________________________ ______________________________________________________Email Address:
Mailing 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: Title:_______________________________________________________________________ ___________________________________
Daytime Phone: Email Address:__________________________________ ________________________________________________
Rae Drawings:
A) First Date of Ticket Sales (mm/dd/yyyy): Date of Rae Drawing (mm/dd/yyyy):________________________ ________________________
Location Address:
Street City State Zip
________________________________________________________________________________________________________
B) First Date of Ticket Sales (mm/dd/yyyy): Date of Rae Drawing (mm/dd/yyyy):
________________________ ________________________
Location Address:
Street City State Zip
________________________________________________________________________________________________________
C) First Date of Ticket Sales (mm/dd/yyyy): Date of Rae Drawing (mm/dd/yyyy):
________________________ ________________________
Location Address:
Street City State Zip
________________________________________________________________________________________________________
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 Officer Signature Secretary Signature
Printed Name Date
Printed Name Date
Page 2
491502
GENERAL INFORMATION
COMPLETED APPLICATION AND FEE: 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
Save time and paper by
ling electronically. See the electronic le and pay options available to by visiting our website at https://www.kdor.
ks.gov/apps/kcsc.
If you have questions you may call 785-368-8222 or email kdor_bingo@ks.gov. Information can be faxed to 785-296-4993.
RAFFLE: Renewals for all charitable gaming licenses are the same as the original license. All charitable gaming licenses expire yearly
on June 30.
INSTRUCTIONS
LICENSE YEAR: Rae licenses are valid July 1, or issuance date, 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”. All questions must be completed. The
Department reserves the right to request additional information or deny the application. The organization must inform the department
within 30 days of any changes in the information supplied in its most recent application led with the department. The rae license will
expire June 30.
NON-PROFIT ORGANIZATION INFORMATION:
Line 1. Enter your 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 organization’s name.
Line 3. Enter the organization’s daytime phone number.
Line 4. Enter the organization’s mailing address.
Line 5. Check the appropriate box for the organization’s non-prot type. Check only one.
Line 6. Check the appropriate box. If the organization is in the process of applying to the IRS, check “Pending”.
ESTIMATED GROSS RECEIPTS: Select the amount of estimated gross receipts for the scal year in which you are applying or
renewing. Remember to include the license fee with your application or renewal. Only those nonprot charitable organizations that have
rae gross receipts exceeding $25,000 shall apply for a rae license. Enter the date that you want this license to become active.
RAFFLE ORGANIZATION’S INFORMATION:
Line 7. Enter the Rae Organization’s name.
Line 8. Enter the Rae Organization’s daytime phone number. including any extension.
Line 9. Enter the Rae Organization’s mailing address where we can send notices.
Line 10. Check the appropriate box. If the organization is in the process of creating by-laws check “pending”.
Line 11. Check “yes” if your organization has been in existence for 18 months or longer. Otherwise, check “no”.
Line 12. Check the appropriate box. If your organization has ever been issued any type of Charitable Gaming license. If “yes”, enter the
name of the business or entity and license number.
Line 13. Check the appropriate box if your organization has ever been denied, revoked or suspended. If “yes”, enter the name of the
business or entity and license information along with the date and reason for denial, revocation or suspension.
PRESIDING OFFICER INFORMATION: Enter the full name, title, daytime phone number, social security number, date of birth, date
assumed oce, email address and mailing address. Check the appropriate box regarding legal violations. If “yes” is selected you must
provide details.
SECRETARY INFORMATION: Enter the full name, daytime phone number, social security number, date of birth, date assumed oce,
email address and mailing address. Check the appropriate box regarding legal violations. If “yes” is selected you must provide details.
RAFFLE COORDINATOR INFORMATION: Enter the full name, daytime phone number, social security number, date of birth, date
assumed oce, email address and mailing address. Check the appropriate box regarding legal violations. If “yes” is selected you must
provide details.
CONTACT PERSON INFORMATION: Enter the full name, title, daytime phone number and email address of the person that can be
contacted regarding your account.
RAFFLE DRAWINGS: Enter the rst date of ticket sales, date of the rae drawing and the location where the rae drawing will be held.
Attach additional pages if more space is needed.
SIGNATURE REQUIRED: This must be completed with the knowledge and consent of both the Presiding Ocer and the Secretary of
the organization whether a new or renewal application is being led.
Page 3
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RAFFLE LICENSE APPLICATION (Kansas Department of Revenue)

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Completed 24 August 2020

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