Form Wv/bgo-1 - Application For Annual, Limited, State Fair Or Super Bingo License
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3STATE OF WEST VIRGINIA
State Tax Department, Charitable Bingo/Raffle Unit
P.O. Box 1143
Charleston, WV 25324-1143
Name
Address
Account #:
City
State
Zip
APPLICATION FOR ANNUAL, LIMITED, STATE FAIR OR SUPER BINGO LICENSE
WV/BGO-1
rtL175 v 10-web
Taxpayers required to file electronically will no longer receive returns for the tax types subject to the mandatory
requirement by mail. Please visit for additional information.
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 license. All Bingo licenses are subject to the Rules & Regulations of the State Tax Commissioner and must be conspicuously
displayed at the location where the Bingo occasion is held. All Bingo occasions shall be open to the general public.
PLEASE NOTE: THIS APPLICATION MUST BE FILED AT LEAST 60 DAYS PRIOR TO THE DATE SCHEDULED FOR THE FIRST BINGO 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
LIMITED LICENSE - $100.00
ANNUAL SENIOR LICENSE - $50.00
STATE FAIR LICENSE - $500.00
ANNUAL LICENSE * - $200.00
SUPER LICENSE - $5000.00
* ONLY APPLICABLE FOR ORGANIZATIONS WHOSE ANNUAL GROSS PROCEEDS ARE LESS THAN $20,000 PER YEAR
Amount Enclosed
.
SECTION 3 - LOCATION OF BINGO OCCASIONS
Address, City, Zip Code & County
Do you own the premises?
YES
NO
(Circle One)
Do you rent or lease the premises?
YES
NO
(Circle One)
List name of owner:
PLEASE NOTE: YOU MUST ATTACH A COPY OF CURRENT RENTAL OR LEASE AGREEMENT WITH THE APPLICATION.
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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