Application For Annual, Limited Or State Fair Raffle License
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1
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3STATE OF WEST VIRGINIA
State Tax Department, Charitable Bingo/Raffle Unit
P.O. Box 1143
Charleston, WV 25324-1143
Craig A. Griffith, Tax Commissioner
Earl Ray Tomblin, Governor
Name
Address
Account #:
City
State
Zip
WV/RAF-1
APPLICATION FOR ANNUAL, LIMITED OR STATE FAIR RAFFLE LICENSE
rtL178 v.8-web
NOTE: This return has been redesigned. To avoid delays in the processing of this return, DO NOT use any older
forms you may have. For information regarding the State Tax Department’s new computer system, visit our
website at
Apply for the license which best serves your needs. You may hold only one valid annual license. While it is valid, you may apply for and
receive one limited occasion 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 DATE SCHEDULED FOR THE FIRST RAFFLE OCCASION.
IS THIS A RENEWAL APPLICATION?
YES
NO
(Check One)
Phone Number of Requesting Organization is Required
NAME AND ADDRESS OF STATE OR NATIONAL ORGANIZATION
Name:
Address:
SECTION 1 - TAX EXEMPT STATUS
Have you been granted tax exempt status from the Internal Revenue Service?
YES
NO
(Check 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)
(Check One)
PLEASE NOTE: YOU MUST ATTACH A COPY OF YOUR CURRENT EXEMPTION LETTER TO THIS APPLICATION.
SECTION 2 - TYPE OF LICENSE (CHECK ONE)
ANNUAL LICENSE - $500.00
Date of your first Raffle Occasion:
Hour(s) Raffle will be held:
LIMITED LICENSE - $50.00
Date of Raffle:
Date of Raffle:
Hour(s) Raffle will be held:
STATE FAIR LICENSE - $500.00
Date of your first Raffle Occasion:
Hour(s) Raffle will be held:
EXEMPT CERTIFICATE
Date of your first Raffle Occasion:
Hour(s) Raffle will be held:
Amount Enclosed
.
MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT
Charitable Bingo/Raffle Unit
P.O. Box 1143, Charleston, WV 25324-1143
FOR ASSISTANCE CALL (304) 558-8510
For more information visit our web site at:
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File online at https://mytaxes.wvtax.gov
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