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

WV/RAF-1
rtL178 v.13-web APPLICATION FOR ANNUAL, LIMITED OR STATE FAIR RAFFLE LICENSE
Taxpayers required to file 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 occasion license.  All Raffle licenses are subject to the Rules & Regulations of the State Tax Commissioner and must be
conspicuously displayed at the location where the Raffle Occasion is held.
PLEASE NOTE: THIS APPLICATION MUST BE FILED AT LEAST 60 DAYS PRIOR TO THE DATE SCHEDULED FOR THE FIRST RAFFLE OCCASION.
IS THIS A RENEWAL APPLICATION?      YES                                   NO                     (Check One)

Phone Number of Requesting Organization is Required

                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)10                                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
Date of your first Raffle Occasion:                                                              Hour(s) Raffle will be held:
LIMITED LICENSE - $50.00
Date of Raffle:                     Date of Raffle:                                              Hour(s) Raffle will be held:
STATE FAIR LICENSE - $500.00
Date of your first Raffle Occasion:                                                              Hour(s) Raffle will be held:
EXEMPT CERTIFICATE
Date of your first Raffle Occasion:                                                              Hour(s) Raffle will be held:

Amount Enclosed
                                                                                                                                           .

                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
                File online at https://mytaxes.wvtax.gov                                                  O     1     2     0     8     0     9     0     1     W

WV/RAF-1
rtL178 v.13-web APPLICATION FOR ANNUAL, LIMITED OR STATE FAIR RAFFLE LICENSE

                       SECTION 3 - LOCATION OF RAFFLE OCCASIONS
Address, City, Zip Code & County

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

                   SECTION 4 - NAMES OF OFFICERS OF ORGANIZATION
LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF ALL OFFICERS AND MEMBERS OF THE BOARD
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 5 - PERSONS IN CHARGE OF RAFFLE
LIST NAMES, HOME ADDRESSES AND TELEPHONE NUMBERS OF PERSONS IN CHARGE OF RAFFLE OCCASIONS. THESE
PERSONS MUST BE BONA FIDE MEMBERS OF YOUR ORGANIZATION AND RESIDENTS OF THE STATE OF WEST VIRGINIA.
ANNUAL LICENSES REQUIRE 3 NAMES. LIMITED LICENSES REQUIRE AT LEAST 2 NAMES. ONE OF THESE PERSONS
MUST BE PRESENT AT ALL RAFFLE OCCASIONS. ALL PERSONS IN CHARGE OF RAFFLE MUST BE OVER 18.
    NAME AND TITLE                      HOME ADDRESS                                     HOME TELEPHONE NUMBER
1.
2.
3.

        SECTION 6 - NAME OF HIGHEST ELECTED OFFICER AND APPOINTED DESIGNEE
LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF THE HIGHEST ELECTED OFFICER AND HIS OR HER
APPOINTED DESIGNEE OF THE 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 7 - YOU MUST ANSWER THE FOLLOWING QUESTIONS

Has your raffle license application ever been refused, denied, revoked, or suspended?    YES     NO     (Circle One)
Has any person in your organization who will participate in any manner in the conduct of Raffle games or related concessions been
convicted of a felony or misdemeanor for a gambling offense within the past 10 years?    YES     NO     (Circle One)
If you answered yes to any of these questions, attach a separate sheet explaining.

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WV/RAF-1
rtL178 v.13-web APPLICATION FOR ANNUAL, LIMITED OR STATE FAIR RAFFLE LICENSE

                               SECTION 8 - NAME OF RAFFLE DISTRIBUTOR
You must list the name, address and phone number of the distributor(s) where you purchase your raffle supplies.
          NAME OF  DISTRIBUTOR                                               ADDRESS                   TELEPHONE NUMBER
1.
2.

                                          SECTION 9 - DISPOSITION OF PROCEEDS

Recipient of Proceeds:
Does this recipient have an Internal Revenue Service Exemption Letter?                  YES     NO     (Circle One)

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 10 - 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. THIS DOCUMENT IS NECESSARY TO QUALIFY FOR A RAFFLE
LICENSE.

                                          SECTION 11 - CONCESSIONS
WILL A CONCESSION BE OPERATED?                                               YES NO     (Circle One)
WILL THE LICENSEE OPERATE THE CONCESSION?                                    YES NO     (Circle One)
PLEASE NOTE: IF THE CONCESSIONS ARE TO BE OPERATED BY SOMEONE OTHER THAN THE LICENSEE, A COPY OF
ANY AGREEMENT OR AN EXPLANATION OF ANY ORAL AGREEMENT PROVIDING ANY  COMPENSATION TO THE
OPERATOR OF THE CONCESSION MUST BE ATTACHED.

                                          SECTION 12 - AGREEMENT
I fully understand that it is a violation of Chapter 47, Article 21 to allow anyone other than authorized persons to conduct any part of the Raffle Games or concessions;  That I am
required to file reports and keep records as provided by Article 21; That it is a crime to violate any provisions of Article 20;  That a violation may result in suspension and/or
revocation of the license and possible denial of future 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)

                   (Telephone Number)                                                   (Email Address)

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