Form 201-R "Charitable Gaming Permit Application - Renewal Applicants Only" - Virginia

What Is Form 201-R?

This is a legal form that was released by the Virginia Department of Agriculture and Consumer Services - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 30, 2013;
  • The latest edition provided by the Virginia Department of Agriculture and Consumer Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 201-R by clicking the link below or browse more documents and templates provided by the Virginia Department of Agriculture and Consumer Services.

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Download Form 201-R "Charitable Gaming Permit Application - Renewal Applicants Only" - Virginia

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FORM 201 - R
VDACS FINANCE CODE: 988-02199
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526, Richmond, VA 23218
(804) 371-0495
www.vdacs.virginia.gov
CHARITABLE GAMING PERMIT APPLICATION - RENEWAL APPLICANTS ONLY
General Instructions
A.
Use this application when applying for renewal of a current valid charitable gaming permit.
B.
Complete the entire application and all attachments. DO NOT LEAVE ANY BLANKS.
C.
Place "N/A" if item is not applicable. Please type or print all answers. Do not use pencil.
D.
If needed, attach additional documents or explanation sheets.
E.
Ensure application is signed/dated by the appropriate individual(s).
F.
Enclose a non-refundable $200 application fee payable to: Treasurer of Virginia. Volunteer Fire Departments and Rescue Squads who have been recognized
by their locality in accordance with Section 15.2-955 of the Code of Virginia, and who can provide a copy of the ordinance or resolution of the locality, are
exempt from the application fee.
G.
Retain a copy for your records.
H.
Mail completed application, applicable fee, and all required attachments to: VDACS, Office of Charitable and Regulatory Programs, PO Box 526, Richmond,
Virginia 23218.
I.
Allow 45 days for processing a COMPLETE application. Incomplete applications and not providing applicable attachments will delay the processing.
J.
Ensure that the applicant has included the area code in each instance where a telephone number is requested.
ORGANIZATION INFORMATION
OCRP No.
1.
Organization's Federal Tax Payer Identification Number
2.
Organization's Name:
Mailing Address:
City:
State:
Zip Code:
Telephone:
Email Address:
Web Page:
3.
Organization's Physical Location:
City:
State:
Zip Code:
Telephone:
Title:
Contact Person:
Contact Person's Daytime Contact Number:
Facsimile:
Email Address:
4.
Jurisdiction where the organization regularly
County of:
City of:
meets?
5.
Total No. of Members:
Total No. of Virginia Residents:
Provide a complete list of members who work in the
management and operation of charitable gaming activities,
Membership list attached with all
Yes or No
including name, address, and membership date.
information?
6.
Has there been any change in the organization's Articles of Incorporation, By-
Laws, Charter, Constitution, and any other organizing documents? If yes,
Yes or No
attach applicable documents.
7.
Type of Tax Exempt Status Obtained from IRS
(Mark "X" at the Appropriate Box) :
3
4
8
501
(c)0
TYPE
10
19
Other - Explain on separate page
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 1 of 12
FORM 201 - R
VDACS FINANCE CODE: 988-02199
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526, Richmond, VA 23218
(804) 371-0495
www.vdacs.virginia.gov
CHARITABLE GAMING PERMIT APPLICATION - RENEWAL APPLICANTS ONLY
General Instructions
A.
Use this application when applying for renewal of a current valid charitable gaming permit.
B.
Complete the entire application and all attachments. DO NOT LEAVE ANY BLANKS.
C.
Place "N/A" if item is not applicable. Please type or print all answers. Do not use pencil.
D.
If needed, attach additional documents or explanation sheets.
E.
Ensure application is signed/dated by the appropriate individual(s).
F.
Enclose a non-refundable $200 application fee payable to: Treasurer of Virginia. Volunteer Fire Departments and Rescue Squads who have been recognized
by their locality in accordance with Section 15.2-955 of the Code of Virginia, and who can provide a copy of the ordinance or resolution of the locality, are
exempt from the application fee.
G.
Retain a copy for your records.
H.
Mail completed application, applicable fee, and all required attachments to: VDACS, Office of Charitable and Regulatory Programs, PO Box 526, Richmond,
Virginia 23218.
I.
Allow 45 days for processing a COMPLETE application. Incomplete applications and not providing applicable attachments will delay the processing.
J.
Ensure that the applicant has included the area code in each instance where a telephone number is requested.
ORGANIZATION INFORMATION
OCRP No.
1.
Organization's Federal Tax Payer Identification Number
2.
Organization's Name:
Mailing Address:
City:
State:
Zip Code:
Telephone:
Email Address:
Web Page:
3.
Organization's Physical Location:
City:
State:
Zip Code:
Telephone:
Title:
Contact Person:
Contact Person's Daytime Contact Number:
Facsimile:
Email Address:
4.
Jurisdiction where the organization regularly
County of:
City of:
meets?
5.
Total No. of Members:
Total No. of Virginia Residents:
Provide a complete list of members who work in the
management and operation of charitable gaming activities,
Membership list attached with all
Yes or No
including name, address, and membership date.
information?
6.
Has there been any change in the organization's Articles of Incorporation, By-
Laws, Charter, Constitution, and any other organizing documents? If yes,
Yes or No
attach applicable documents.
7.
Type of Tax Exempt Status Obtained from IRS
(Mark "X" at the Appropriate Box) :
3
4
8
501
(c)0
TYPE
10
19
Other - Explain on separate page
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 1 of 12
ORGANIZATION INFORMATION
Type of Organization - Please
8.
Veterans
Community
Fraternal
place an "X" in the appropriate
box.
Religious
Charitable
Educational
Other - Explain:
9.
In the last three years, has the organization had a 501(c) status with the
If yes, please explain on a
Internal Revenue Service revoked or suspended?
separate page.
Yes or No
10.
Is the organization in compliance with Federal and State law relative to the
filing, in the last three tax years, of mandated Federal and State tax returns
If no, please explain on a
(i.e ., 990, 990EZ, 990T, 990PF, etc.)?
Yes or No
separate page.
11.
What is the tax period and year of the organization's most recently filed
Internal Revenue Service tax Form 990 (including, but not limited to, Form
990, 990EZ, 990 PF, 990T) or applicable tax return that has been officially
filed and received by the IRS? If no return has been filed, please explain on
a separate page.
Month/Date/Year
Amount
reported on
Line 9.a. of the
Please provide the Total Gross Revenue from Special Events and Activities
Form 990
(Charitable Gaming) as reported to the Internal Revenue Service relative to
the charitable gaming activities conducted by the organization on Form 990 -
Amount
Return of Organization Exempt from Income Tax. If the organization has
reported on
been formally recognized by the IRS as a church, then attach the most
Line 6. of the
recent Statement of Income and Receipts, and Balance Statement.
Short Form 990
12.
If your organization is a part of or related to a national office of an
organization (See . Section 18.2-340.24.A.1.(i.), Code of Virginia, 1950, as
amended), please provide a letter of good standing from the national
organization which indicates that your organization is currently covered by
the group exempt ruling. If the national and/or state office has provided this
information to the Office for the current year, please select N/A (not
applicable).
Yes or No
Copy attached?
If this is not applicable to your organization, place an "X" in the box.
Not Applicable
13.
Is your organization recognized as a corporation or a form of limited liability
If no, explain on a separate page
how the organization is exempt
company, as defined by the Code of Virginia, and authorized to do business
from this requirement.
in Virginia?
Yes or No
Yes
If you answered yes to Item No. 13, is the name as registered at the Virginia
State Corporation the same as provided under Item No. 2 of this application.
If no, please print registration name below.
Yes or No
14.
If you answered yes to Item No. 13, is your organization in good standing
If no, please explain on a
with the Virginia State Corporation Commission?
separate page.
Yes or No
15.
Is the organization registered and in good standing with the Virginia
If no, please explain on a
separate page how the
Department of Agriculture and Consumer Services to solicit charitable
organization is exempt from
contributions in Virginia?
Yes or No
registration.
If you answered Yes to Item No. 15, is the name as registered at the Virginia
Department of Agriculture and Consumer Services the same as provided
under Item No. 2 of this application. If No, please print registration name
below.
Yes or No
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 2 of 12
ORGANIZATION INFORMATION
16.
Has any officer, director, or game manager who participates in the
management or operation of any charitable gaming activity ever been (a)
convicted of a felony, (2) convicted of any misdemeanor involving fraud,
theft or financial crimes within the preceding five years of this application, or
(3) participated in the management, operation or conduct of any charitable
game which was found by the Office or a court of competent jurisdiction to
If Yes, please provide name,
have been operated in violation of state law, local ordinance, or Office
address, and details on a
Yes or No
regulation within the last five years?
separate page.
17.
Has any officer, director, or game manager who participates in the conduct
of any charitable gaming activity been (a) convicted of a felony in the
preceding ten years, (2) convicted of any misdemeanor involving fraud, theft
or financial crimes within the preceding five years of this application, or (3)
participated in the management, operation or conduct of any charitable
game which was found by the Office or a court of competent jurisdiction to
If Yes, please provide name,
have been operated in violation of state law, local ordinance, or Office
address, and details on a
regulation within the last five years?
Yes or No
separate page.
18.
Is any officer, director, game manager, member, or any member who
volunteers in the conduct, operation, or management of charitable gaming
activities related to a registered supplier, supplier's agent, employee,
member of the supplier's immediate family or person residing in the same
If yes, please explain and
household who offers, provides, or sells gaming products to your
provide details on a separate
Yes or No
organization?
page.
CHARITABLE GAMING ACTIVITIES
19.
List the location(s), day(s), date(s) and time(s) the charitable gaming activity(s) will be held:
(List all planned activities below. If more
space is needed or your organization utilizes additional facilities, provide the same information relative to the additional facility on a separate page and attach.)
Building Name (Where Charitable Gaming
Activities Will Be Held):
Physical Address:
City/Town:
State:
Zip Code:
Official Jurisdiction (County of/City of):
Annual Pull Tab Event -
Type of Gaming Activity -
Qualified Association,
Please an "X" by the
Stand Alone
Booster Club, etc. (See .
appropriate box.
Raffle
Bingo
Section 18.2-340.26:2)
Day(s) of the Week and/or Frequency of Gaming Activities:
Doors Open at Facility
Doors Close at Facility
Begin Game Time
End Game Time
Maximum Occupancy
Total Square Footage Used
Facility Charges Per Session:
Facility Lease
$
Equipment Lease
$
Has the organization identified any and all payments and/or consideration paid to the
landlord? If no, please explain on a separate page and identify each and every charge,
Yes or No
and the amount.
20.
A qualified athletic association, or booster club or a band booster club created solely to
raise funds for school-sponsored athletic or band activities for a public school or private
If not applicable
accredited school (in accordance with § 22.1-19 - Code of Virginia) or to provide
to the applicant
scholarships to students attending such school wishing to conduct an annual pull tab event
organization,
must submit with this application a narrative describing the event. Is narrative attached to
please leave
Yes or No
blank.
this application for this type of event?
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 3 of 12
CHARITABLE GAMING ACTIVITIES
21.
(If more space is needed or your organization utilizes additional facilities, provide the
FOR ALL CHARITABLE GAMING ACTIVITIES:
same information relative to the additional facility on a separate page and attach.)
a.
Who owns and has title to the facility where the charitable gaming
Organization
Yes or No
activities will occur. Check one.
Leased
Yes or No
Other - Explain:
If the applicant organization does not own and have title to the facility,
attach a copy of the current lease that authorizes the organization to
use the facility in the conduct of charitable gaming activities, including
Is lease
bingo and raffle(s).
Yes or No
attached?
b.
Is the equipment used to conduct the charitable gaming activities
owned or leased by the applicant organization? If leased, list the
Owned?
Yes or No
name, address, and contact number of the lessor of the equipment.
If leased, attach a separate page with the name of the owner, address, and
Leased?
Yes or No
contact number.
c.
Landlord Full Name:
Landlord Address:
City:
State:
Zip Code:
Contact Person:
Telephone:
Facility
d.
Name of Facility:
Manager:
Facility Telephone:
Facility Facsimile:
22.
Are the premises used by more than one organization for the purpose of conducting
charitable gaming activities? If yes, please provide the name and address of each
organization utilizing this facility on a separate page.
Yes or No
Yes
23.
For Raffle Applications Only - Will the raffle event be held in conjunction with a casino or Las Vegas
night? Please complete the following for each scheduled raffle.
Yes or No
a.
What date does the organization plan to begin raffle ticket sales?
Tickets cannot be sold until receipt of a valid charitable gaming permit.
Month/Date/Year
Raffle drawing date and time of drawing.
Month/Date/Year
Time
b.
What is the prize to be given away? Use a separate page if needed.
c.
Were the prize(s) purchased and/or donated?
(Use separate page if necessary. Check one box for each prize as to prize being
purchased or donated.) Please indicate fair market value of each prize.
$
Purchased
Yes or No
$
Purchased
Yes or No
Donated
Yes or No
Donated
Yes or No
d.
What is the total purchase price per ticket? (
.) Attach a
Use separate page if necessary
copy of each sample raffle ticket. See. 11 VAC 15-22-70.C. for required
$
information.
e.
Will volunteers/members who sell raffle tickets be allowed to buy raffle tickets? If
Yes or No
yes, please provide a detailed explanation.
f.
Provide a narrative detailing how the raffle will be conducted, its scope, who will be
Copy
responsible for its oversight, and all rules of play, i.e ., what happens if not enough
attached?
Yes or No
tickets are sold or how many days a winner has to claim the prize.
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 4 of 12
CHARITABLE GAMING ACTIVITIES
24.
Are all raffle tickets scheduled to be sold in the Commonwealth of Virginia? If no, provide
an explanation of how raffle sales will be conducted if not sold in Virginia.
Yes or No
Yes
25.
Full name of person responsible for filing financial reports:
First
Middle
Last
Relationship to Organization:
Street Address:
City:
State:
Zip Code:
Telephone:
Email Address:
Facsimile:
Where are the financial records stored?
26.
Organization
Other
Physical Address:
City:
State:
Zip Code:
Telephone:
Contact Person Full Name:
Facsimile:
First Name
Middle Name
Last Name
27.
Please list the name of any and all individuals and/or registered suppliers
who have offered and/or sold gaming supplies to your organization during
Have all suppliers of gaming
the last 12 months, or who the organization anticipates obtaining charitable
products utilized by your
gaming supplies from. Use additional sheet if necessary.
Yes or No
organization been identified?
a.
Yes
Supplier Name:
b.
Supplier Name:
c.
Supplier Name:
28.
Does the organization pay or anticipate paying any caller or bingo manager
If yes, please list each individual
for participating in the organization's charitable gaming activities? Use
below and the individual's current
additional pages if necessary.
Yes or No
BMR/BCR #.
Full Name of Individual
Title
Caller, Manager or Both
BMR/BCR #
Full Name of Individual
Title
Caller, Manager or Both
BMR/BCR #
29.
Describe in detail how the funds derived from the organization's charitable gaming activities will be disbursed in accordance with
those lawful religious, charitable, community or educational purposes.
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 5 of 12
Page of 12