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STATE OF WEST VIRGINIA
State Tax Department, Charitable Bingo/Raffle Unit
P.O. Box 1143
Charleston, WV 25324-1143

Name

Address Account#:
City State Zip

wvmoo-1 APPLICATION FOR ANNUAL, LIMITED, STATE FAIR OR SUPER BINGO LICENSE
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Taxpayers required to me electronically will no longer receive returns for the tax types subject to the mandatory
requirement by mail. Please visit www.tax.wv.gov for additional information.
Apply for the license which best serves your needs You. may hold only one valid annual license. While it is valid, you may apply for and
receive one limited license All. Bingo licenses are subject to the Rules & Regulations ofthe State Tax Commissioner and must be conspicuously
displayed at the location where the Bingo occasion is held All. Bingo occasions shall be open to the general public .
PLEASE NOTE TIDS: APPLICATION MUST BE FILED AT LEAST 60 DAYS PRIOR TO THE DATE SCHEDULED FOR THE FIRST BINGO OCCASION.
IS TIDS A RENEW AL APPLICATION? YES □ NO □ (Check One)

Phone Number of Requesting Organization is Required
I
NAME AND ADDRESS OF STATE OR NATIONAL ORGANIZATION
Name:
Address:

SECTION 1-TAX EXEMPT STATUS
Have you been granted tax exempt status from the Internal Revenue Service? YES □ NO (Check One)
□
TYPE OF EXEMPTION LETTER YOUR ORGANIZATION POSSESSES
501(C)3 □ 501(C)4 □ 501(C)8 □ 501(C)I0 □ 501(C)19 □ 501(D) (Check One)
□
PLEASE NOTE: YOU MUST ATTACH A COPY OF YOUR CURRENT EXEMPTION LETTER TO THIS APPLICATION.

SECTION 2 -TYPE OF LICENSE (CHECK ONE)
ANNUAL LICENSE - $500.00 LIMITED LICENSE- 100$ 00.
□ □
ANNUAL SENIOR LICENSE - $50 00. STATE FAIR LICENSE - $500 00.
□ □
ANNUAL LICENSE * -$200.00 SUPER LICENSE - $5000 00.
*ONLY APPLICABLE□ FOR ORGANIZATIONS WHOSE ANNUAL GROSS PROCEEDS□ ARE LESS THAN $20,000 PER YEAR
Amount Enclosed
I .
SECTION 3 -LOCATION OF BINGO OCCASIONS
Address, City, Zip Code & County

Do you own the premises? YES NO (Circle One) Do you rent or lease the premises? YES NO (Circle One)
List name of owner:
PLEASE NOTE YOU: MUST ATTACH A COPY OF CURRENT RENTAL OR LEASE AGREEMENT WITH THE APPLICATION.

MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT
Charitable Bingo/Raffle Unit
P.O. Box 1143, Charleston, WV 25324-1143
FOR ASSISTANCE CALL (304) 558-8683
For more information visit our web site at: www.tax.wv.gov 111111111111111 I Ill Ill II
File online athttps://mvtaxes.wvtax.2ov O21080901W

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wvlBGo-1  APPLICATION FOR ANNUAL, LIMITED, STATE FAIR OR SUPER BINGO LICENSE 
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          SECTION 4 - DATES AND TIMES OF ANNUAL AND SENIOR BINGO OCCASIONS 
Please indicate the day(s) of the week your Bingo occasion(s) will be conducted and give the actual playing time: 
MONDAY             TUESDAY      WEDNESDAY        TlillRSDAY       FRIDAY     SATURDAY  SUNDAY  (Circle Days Played) 
Date of your first Bingo Occasion:                                     Hour(s) Bingo will be held: 

                    SECTION 5 - DATES AND TIMES OF LIMITED BINGO OCCASIONS 
A limited occasion license entitles an organization to hold a Bingo occasion once every 24 hours for a period not to exceed 2 
weeks.An occasion may not exceed        12hours duration. No more than three (3) Limited Licenses may     begranted in one year. 
List the actual dates and playing times Bingo will be conducted. 
HOLDERS OF ANNUAL LICENSES MAY BE GRANTED NO MORE THAN ONE LIMITED LICENSE PER YEAR. 
Date of Bingo:     ________ _                    Date of Bingo: ________ _                   Time ofBingo(s): _______ _ 

                   SECTION 6 - DATES AND TIMES OF STATE FAIR BINGO OCCASIONS 
STATE FAIR: AN APPLICATION FOR A STATE FAIR LICENSE MUST INCLUDE A COPY OF ANY LEASE 
AGREEMENT ENTERED INTO BETWEEN THE STATE FAIR BOARD AND THE PERSONS WHO ARE TO 
CONDUCT THE BINGO OCCASIONS. 
Has the operator of the Bingo occasions conducted Bingo at the State Fair for at least 2 years prior to the filing of this 
application?        YES    NO       (Circle One) 
Date of your first Bingo Occasion:                                     Hour(s) Bingo will be held: 

                    SECTION 7 - DATES AND TIMES OF SUPER BINGO OCCASIONS 
1    Date                                                Time                                     to 
2    Date                                                Time                                     to 
3    Date                                                Time                                     to 
4    Date                                                Time                                     to 
5    Date                                                Time                                     to 
6    Date                                                Time                                     to 
7    Date                                                Time                                     to 
8    Date                                                Time                                     to 
9    Date                                                Time                                     to 
10   Date                                                Time                                     to 
11   Date                                                Time                                     to 
12   Date                                                Time                                     to 

     SECTION 8 - PROOF OF EXISTENCE (NOT REQUIRED FOR RENEWAL APPLICANTS) 
HAS YOUR ORGANIZATION BEEN IN EXISTENCE IN WEST VIRGINIA TWO YEARS PRIOR TO FILING THIS APPLICATION: 
YES             NO      (Circle One) 
IF YES, YOU MUST ATTACH DOCUMENTARY PROOF        .  nnsDOCUMENT IS N CESSARYE    TO QUALIFY FOR A BINGO LIC NSEE      . 

                                                 SECTION 9 - CONCESSIONS 
WILL A CONCESSION BE OPERA TED?                          YES      NO             (Circle One) 
WILL THE LICENSEE OPERATE THE CONCESSION?                YES      NO             (Circle One) 
PLEASE NOTE: IF THE CONCESSIONS ARE TO BE OPE RATED BY SOMEONEOTHER THAN THE LICENSEE, A COPY O ANYF A REGMENTE ORAN 
EXPLANATION OF ANY ORAL AGRE MENTE  PROVIDING OF ANYTYPE OF COMP NSATIONE OF THE CONC SSIONE MUST B ATTACHEDE   . 

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wvlBGo-1 APPLICATION FOR ANNUAL, LIMITED, STATE FAIR OR SUPER BINGO LICENSE
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SECTION 10 -NAMES OF OFFICERS OF ORGANIZATION
LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF ALL OFFICERS AND MEMBERS OF THE BOARD OF
DIRECTORS, GOVERNORS OR TRUSTEES, IF ANY, IN THE ORGANIZATION. ALL OFFICERS MUST BE OVER 18. (ATTACH ADDITIONAL
SHEET IF NECESSARY)
NAME AND TITLE HOME ADDRESS HOME TELEPHONE NUMBER
1.
2.
3.
4 .

SECTION 11 - PERSONS IN CHARGE OF BINGO
LIST NAMES, HOME ADDRESSES AND TELEPHONE NUMBERS OF PERSONS IN CHARGE OF BINGO OCCASIONS . THESE PERSONS MUST
BE BONA FIDE MEMBERS OF YOUR ORGANIZATION AND RESIDENTS OF THE ST A TE OF WEST VIRGINIA. ANNUAL LICENSES REQUIRE 3
NAMES. LIMITED LICENSES REQUIRE ATLEAST 2 NAMES ONE. OF THESE PERSONS MUST BEPRESENTATALL BINGO OCCASIONS.
ALL PERSONS IN CHARGE OF BINGO MUST BE OVER 18.
NAME AND TITLE HOME ADDRESS HOME TELEPHONE NUMBER
1.
2.
3.

SECTION 12 -NAME OF HIGHEST ELECTED OFFICER AND APPOINTED DESIGNEE
LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF THE HIGHEST ELECTED OFFICER AND HIS APPOINTED DESIGNEE OF
ORGANIZATION. ONE OF THESE PERSONS MUST BE PRESENT AT ALL OCCASIONS. ALL PERSONS MUST BE OVER 18.
NAME AND TITLE HOME ADDRESS HOME TELEPHONE NUMBER
HIGHEST ELECTED OFFICER
1.
APPOINTED DESIGNEE
2.

SECTION 13 -YOU MUST ANSWER THE FOLLOWING QUESTIONS
Has your Bingo License Application ever been refused, denied, revoked, or suspended? YES NO

concessionsHas any personeverinbeenyour Organizationconvictedofwhoa FelonywillorparticipateMisdemeanorin anyformannera gamblingin theoffenseconductwithinoftheBingopastGames10 years?or related YES NO
If you answered yes to any of these questions, attach a separate sheet explaining.

SECTION 14 -DISPOSITION OF PROCEEDS

Recipient of Proceeds:
Does this recipient have an Internal Revenue Service Exemption Status Letter? YES NO

Intended use of Proceeds :
PLEASE NOTE YOU: MUST LIST THE NAMES OF ALL ORGANIZATIONS YOU INTEND TO DONATE PROCEEDS TO. ATTACH SEPARATE SHEET IF NECESSARY.

SECTION 15 -AGREEMENT
I fully understand tbat it is a violation ofChapter 47,Article 20 to allow anyone otber tban authorized persons to conduct any part oftbe Bingo Games or Concessions; That I am
required to file reports and keep records as provided by Article 20 That ; is aitcrime to violate any provisions ofArticle 20; That a violation may result in suspension or
revocation of tbe license and possible denial of subsequent license applications.

I, , AS AN AUTHORIZED REPRESENTATIVE OF
CERTIFY OR AFFIRM THAT THE STATEMENTS AND ITEMS ENTERED HEREIN AND ATTACHED HERETO ARE TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE.
(Name - Type or Print) (Signature) (Date)

(Teleohone Number) <Email Address)

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