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Get AR AR-1R-BRLAO 2014-2021

Print Form ARKANSAS DEPARTMENT OF FINANCE AND ADMINISTRATION Bingo and Raffle Registration Licensed Authorized Organization Supplemental Form Clear Form AR-1R-BRLAO SECTION A OWNERSHIP INFORMATION 1 Legal Name Enter full legal name of organization - 2 Federal Identification Number FEIN SECTION B EVENT LOCATION INFORMATION 3 Location of event s Address City State Zip Check the appropriate box Premises are owned by the organization Premises are leased/rented by the organization - Attach copy of lease agreement Other explain SECTION C LICENSE TYPE 4 Type of License Original Renewal A 100. 00 Annual fiscal license to operate games of bingo and raffle B 25. 00 Temporary license to conduct one bingo session C 25. 00 Class I temporary license to conduct one raffle D 10. 00 Class II temporary license to conduct one raffle Prize donated and has a value less than 5 000. 00 If renewal application supply existing 8 digit Account ID -BRR SECTION D NON-PROFIT CERTIFICATION AND EVENT INFORMATION 5 Is the organization incorporated under 26 U*S*C. Section 501 Yes - Attach a copy of acceptance and approval letter from the US Internal Revenue Service reflecting 5 years of non-profit status. Additional information will be required if less than 5 years. No - Attach documents supporting requirement that applying non-profit organization has been in existence a minimum of 5 years. 6 Indicate the type of organization and date organized Religious Service Veterans Educational Medical Volunteer Fire/Rescue Fraternal Civic Volunteer Police Non-profit Tax-exempt instrumentality of the United States Government 7 List the charitable purpose s of net proceeds from Bingo/Raffle events 8 Annual license - Enter event times the organization will operate bingo. Note Organizations are limited to 2 bingo events per week which last no more than 5 hours each. Sunday to Tuesday Thursday Monday Wednesday Friday Saturday 9 Temporary license - Enter date which the temporary Bingo/Raffle session will be held SECTION E RESPONSIBLE PARTY CERTIFICATION 10 I certify that as the responsible party for the above mentioned organization that I have not been found guilty or plead guilty to a felony in the State of Arkansas or any similar offense by a court in another state or of any similar offense by a military or federal court. 00 Annual fiscal license to operate games of bingo and raffle B 25. 00 Temporary license to conduct one bingo session C 25. 00 Class I temporary license to conduct one raffle D 10. 00 Class II temporary license to conduct one raffle Prize donated and has a value less than 5 000. 00 Class I temporary license to conduct one raffle D 10. 00 Class II temporary license to conduct one raffle Prize donated and has a value less than 5 000. 00 If renewal application supply existing 8 digit Account ID -BRR SECTION D NON-PROFIT CERTIFICATION AND EVENT INFORMATION 5 Is the organization incorporated under 26 U*S*C. 00 If renewal application supply existing 8 digit Account ID -BRR SECTION D NON-PROFIT CERTIFICATION AND EVENT INFORMATION 5 Is the organization incorporated under 26 U*S*C. Section 501 Yes - Attach a copy of acceptance and approval letter from the US Internal Revenue Service reflecting 5 years of non-profit status. .

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