Form Wv/raf-1 - Application For Regular Annual, Limited Or State Fair Raffle License
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2WV/RAF-1
West Virginia State Tax Department
Rev. 09/05
Charitable Bingo/Raffle Unit
PO Box 1143
Charleston WV 25324-1143
304-558-8510
APPLICATION FOR REGULAR ANNUAL, LIMITED OR STATE FAIR RAFFLE LICENSE
TAX IDENTIFICATION NUMBER
TELEPHONE:
R
NAME:
ADDRESS:
Apply for the license which best serves your needs. You may hold only one valid regular annual license. While it is valid, you may apply and receive
one limited 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
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DATE SCHEDULED FOR THE FIRST RAFFLE OCCASION.
IS THIS A RENEWAL APPLICATION?
YES
NO
(Circle One)
1. 501(C) STATUS
Have you been granted 501(c) tax exempt status from the Internal Revenue Service?
YES
NO (Circle 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) (Circle One)
PLEASE NOTE: YOU MUST ATTACH A COPY OF YOUR CURRENT 501(C) EXEMPTION LETTER TO THIS APPLICATION.
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2. TYPE OF LICENSE
_____ANNUAL LICENSE $500.00
Annual license is valid from January to December. License is not transferable. Holders of annual license may not hold joint raffle occasions. License
must be conspicuously displayed where the raffle occasions are held.
Date of your first Raffle Occasion:
Hour(s) Raffle will be held:
_____LIMITED LICENSE $50.00
Entitles an organization to hold two (2) raffle occasions not to exceed six (6) months from the issuance of the license. No more than three (3)
licenses may be granted in one year. List the actual dates and playing times Raffle will be conducted. HOLDERS OF ANNUAL LICENSES MAY BE
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GRANTED NO MORE THAN ONE (1) LIMITED LICENSE PER YEAR.
Date of Raffle
Date of Raffle:
Hour(s) Raffle will be held:
_____STATE FAIR LICENSE $500.00
An application for a state fair license must include a copy of any lease agreement entered into between the state fair board and the persons who
are to conduct the raffle occaions
Date of your first Raffle Occasion:
Hour(s) Raffle will be held:
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_____EXEMPT CERTIFICATE
In order to qualify for an exempt raffle license, the value of any prize may not exceed $4000.00 and the gross proceeds may not exceed $15,000.00
Date of your first Raffle Occasion:
Hour(s) Raffle will be held:
3. 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)
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IF YES, YOU MUST ATTACH DOCUMENTARY PROOF, THIS DOCUMENT IS NECESSARY TO QUALIFY FOR A RAFFLE LICENSE.
4. 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 OF ANY TYPE OF COMPENSATION OF THE CONCESSION MUST BE ATTACHED.
FOR OFFICE USE ONLY
Date Approved:
Approved By:
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