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

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Download "Electronic Payment Request Form" - Kentucky

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Electronic Payment Request Form
Department of Charitable Gaming
500 Mero Street 2NW24
Frankfort, Kentucky 40601
(502) 573-5528 or (800) 729-5672
FAX (502) 573-6625
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
500 Mero Street 2NW24
Frankfort, Kentucky 40601
(502) 573-5528 or (800) 729-5672
FAX (502) 573-6625
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