"Electronic Payment Request Form" - Kentucky

Electronic Payment Request Form is a legal document that was released by the Kentucky Department of Charitable Gaming - a government authority operating within Kentucky.

Form Details:

  • The latest edition currently provided by the Kentucky Department of Charitable Gaming;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Kentucky Department of Charitable Gaming.

ADVERTISEMENT
ADVERTISEMENT

Download "Electronic Payment Request Form" - Kentucky

1058 times
Rate (4.4 / 5) 53 votes
Electronic Payment Request Form
Department of Charitable Gaming
132 Brighton Park Blvd
Frankfort KY 40601
(502) 573-5528 or (800) 729-5672
FAX (502) 573-6625
www.DCG.KY.GOV
Please complete the following information:
License Number
___________________________________
Name of Licensee
___________________________________
Mailing Address
___________________________________
Name and Title of Officer Requesting Electronic Payment ________________________________
Name of Bank ____________________________________
Name of Account as it Appears on Statement ___________________________________________
9 Digit Routing Number _____________________________
Account Number __________________________
Description of Payment (i.e. Renewal Fees, Financial Report Fees, etc) ______________________
Amount ________________________________
All payments must be made by the organization’s charitable gaming account.
Electronic Payments may be submitted by US mail, fax, or email to:
Stephanie Ledford, Fiscal Officer
Stephanie.Ledford@ky.gov
Electronic Payment Request Form
Department of Charitable Gaming
132 Brighton Park Blvd
Frankfort KY 40601
(502) 573-5528 or (800) 729-5672
FAX (502) 573-6625
www.DCG.KY.GOV
Please complete the following information:
License Number
___________________________________
Name of Licensee
___________________________________
Mailing Address
___________________________________
Name and Title of Officer Requesting Electronic Payment ________________________________
Name of Bank ____________________________________
Name of Account as it Appears on Statement ___________________________________________
9 Digit Routing Number _____________________________
Account Number __________________________
Description of Payment (i.e. Renewal Fees, Financial Report Fees, etc) ______________________
Amount ________________________________
All payments must be made by the organization’s charitable gaming account.
Electronic Payments may be submitted by US mail, fax, or email to:
Stephanie Ledford, Fiscal Officer
Stephanie.Ledford@ky.gov