1752 Form Pa PDF Details

1752 Form Pa is the Pennsylvania income tax form. This form is used to report all of your income and taxable deductions for the year. You will need to complete this form if you are required to file a Pennsylvania state income tax return. Be sure to include all of your taxable income on this form, and remember to claim any deductions that you are eligible for. The deadline for submitting this form is April 15th. If you have any questions about completing this form, be sure to consult a tax professional.

QuestionAnswer
Form Name1752 Form Pa
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namespa small game of chance application form, pa eligible organization games of chance application, games of chance license pa, pa games of chance license

Form Preview Example

REV-1752 (AS) 05-18

Please submit form to the appropriate licensing authority.

ELIGIBLE ORGANIZATION

GAMES OF CHANCE

APPLICATION

Please Print or Type.

FOR LICENSING AUTHORITY

USE ONLY

IMPORTANT: READ INSTRUCTIONS ON PAGE 4 BEFORE COMPLETING APPLICATION

Licensing Authority

Street Address

County or Governing Authority Name

Phone Number

 

 

 

City

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

1. Check Appropriate Block:

Initial Application

Annual Application

Monthly Application

Change of Data

The licensing authority must be notified of changes to the information included on this application within 15 days of the change.

2. Submit a check, cashier’s check or money order payable to the licensing authority named above for the fee due.

 

TYPE OF APPLICATION

FEE

EXPLANATION

 

 

Game of Chance License

$125.00

Required for application.

 

 

Monthly License

$25.00

Required for application.

 

 

Replacement License

➡

Issued only if defaced, destroyed or lost. Contact the licensing authority for current fee.

 

 

 

3.

Name of Municipality (city, borough, incorporated town or township)

4a. Liquor Identification Number (LID)

 

 

 

5.

Indicate Type of Organization (See instructions on Page 4.)

4b. Liquor License Number (if applicable)

 

 

 

 

 

 

 

 

 

6. If incorporated, check here and attach

 

 

 

 

copy of articles of incorporation.

 

 

 

 

7. Name of Organization

 

 

8. Date organization was formed

 

 

 

 

 

9.Location of Organization AND LICENSED PREMISES A. Address of Normal Business or Operating Site

Street Address

 

 

City

State

ZIP Code

 

 

 

 

 

 

County

Phone Number

Email Address

 

 

 

 

 

 

 

 

B. Mailing Address

Check if same as 9a

 

 

 

 

 

 

 

 

 

Street Address

 

City

 

State

ZIP Code

 

 

 

 

 

 

County

 

 

Phone Number

 

 

 

 

 

 

 

C. Licensed Premises Check if same as 9a

Street Address

City

State

ZIP Code

 

 

County

Phone Number

Licensed Premises is (check applicable box)

Owned by organization

Leased by organization

Owned or Leased by another licensed eligible organization and

 

 

leased to or used by the organization

Other (Explain):

THIS FORM MAY BE REPRODUCED

Page 1

10.A. Eligible organization’s operating day

B.Eligible organization’s operating week

11.As the executive officer or secretary of the eligible organization, I certify, under penalties of perjury and falsification found in

18 Pa. C.S.A. §4901 et seq., that:

A.No person under 18 years of age shall be permitted to operate or play games of chance.

B.No person who will manage, set up, supervise or participate in the operation of games of chance has been convicted of a felony, a violation of the Bingo Law, or the Local Option Small Games of Chance Act.

C.The facility in which games of chance are to be played has adequate means of ingress and egress and adequate sanitary facilities available in the area and meets all Department of Health and other local or federal sanitary requirements.

D.The eligible organization is the owner of the premises upon which the games of chance are played; or, if it is not, the organization is not leasing such premises from the owner under an oral agreement, nor is it leasing such premises from the owner under a written agreement as a rental which is determined by the amount of receipts realized from the playing of games of chance or by the number of people attending, except for a banquet where a per head charge is applied connecting to the serving of a meal.

E.The organization has not been convicted of a violation of the Act of Dec. 19, 1988 (P.L. 1262, No. 156), known as the Local Option Games of Chance Act.

I have examined this application, including accompanying schedules and statements, and to the best of my knowledge and belief, all in- formation provided is true, correct and accurate.

Signature of Officer Preparing Application

Date of Birth

Title

Date

 

 

 

 

Print Name

 

Social Security Number (Optional)

Telephone Number

 

 

 

 

12.COMMONWEALTH OF PENNSYLVANIA COUNTY OF

Before me this day personally appeared

 

 

 

 

, who, being duly sworn

according to law, deposes and says that the statements contained in the foregoing application are true and correct.

Subscribed and sworn to before me this date:

 

 

 

 

 

 

 

Month

Day

Year

(Seal)

My commission expires on

 

.

Notary Signature

FALSE OR FRAUDULENT APPLICATION IS PUNISHABLE BY A FINE OF $1,000, IMPRISONMENT FOR ONE YEAR OR BOTH.

THE FOLLOWING DOCUMENTS MUST BE ATTACHED TO THE APPLICATION (use 8 1/2” X 11” sheets where possible).

1.Check, cashier’s check or money order in the amount of the total application fee payable to the licensing authority named on Page 1 of this application.

2.Schedule Sheet.

3.If incorporated, a copy of the applicant’s articles of incorporation. If not incorporated, a copy of bylaws or other legal documents that define the organization’s structure and purposes. Documentation indicating the organization has been fulfilling its purpose for one year prior to applying for a license is required.

4.A copy of the applicant’s Internal Revenue Service tax exemption approval letter or official documentation indicating the applicant is a non-profit charitable organization.

5.Details and copies of all written lease or rental arrangements between the applicant and the owner of premises upon which the games of chance will be conducted, if such premises are leased or rented. If premises are owned, provide a copy of the deed.

6.Each club that was required to file a games of chance report with the Department of Revenue during the prior license term must attach a copy of the report with this application.

Page 2

REV-1752 (AS) 05-18

SCHEDULE SHEET FOR ELIGIBLE

ORGANIZATION GAMES OF CHANCE

LICENSING

Please Print or Type All Information.

SCHEDULE A – Check which type(s) of games of chance the organization will conduct:

 

Daily/Weekly Drawings

Pull-tab games

Punchboards

Raffles

Race Night Games

Pools

50/50 Drawings

 

 

 

 

 

SCHEDULE B – List the following data for all officers, directors, owners and partners. If incorporated, list all officers and shareholders controlling 10 percent or more of outstanding stock. If organized as a partnership, list data for all partners. For all other entities, list data of any other financially responsible person.

Full Name

Date of Birth

Title or Relationship

Social Security Number (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name

Date of Birth

Title or Relationship

Social Security Number (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

Telephone Number

Complete Mailing Address

SCHEDULE C – List all persons who will be responsible for operation of games of chance, including employees, bar personnel and organizational members or auxiliary members who will obtain and coordinate use of games of chance.

Full Name

Date of Birth

Title or Relationship

Social Security Number (Optional)

 

 

 

 

Complete Mailing Address

 

 

Telephone Number

 

 

 

 

Full Name

Date of Birth

Title or Relationship

Social Security Number (Optional)

 

 

 

 

Complete Mailing Address

 

 

Telephone Number

 

 

 

 

Full Name

Date of Birth

Title or Relationship

Social Security Number (Optional)

 

 

 

 

Complete Mailing Address

 

 

Telephone Number

 

 

 

 

SCHEDULE D - List distributors with which the organization anticipates doing business:

Name of Distributor and Distributor License Number

Complete Mailing Address

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHEDULE E – List all auxiliary groups of the applicant conducting games of chance under the applicant’s license:

1.

2.

3.

4.

5.

THIS FORM MAY BE REPRODUCED

Page 3

REV-1752 IN (AS) 05-18

Pennsylvania Department of Revenue

Instructions for REV-1752 Eligible Organization Games of Chance Application

The licensing authority (County Treasurer, or in any home-rule county where there is no elected treasurer, the designee of the governing authority) should enter the county name or governing authority name, address and telephone number in the space provided at the top of the application prior to making application forms available to the local eligible organizations.

Questions regarding games of chance and this application should be referred to the licensing authority on Page 1 at the top of the application. If the information is missing, refer to the government section of your local telephone book to determine the name and address of your county licensing authority.

 

 

APPLICATION INSTRUCTIONS

SECTION 1

–

Applicant must check the appropriate block to indicate the type of application the organization is submitting.

SECTION 2

–

Check type of application.

 

–

Games of Chance License - A games of chance license authorizes the licensee to conduct games of chance

 

 

during the eligible organization’s licensing term. A licensee is eligible to apply for special raffle permits.

 

–

A monthly license authorizes an eligible organization to conduct games of chance for a 30 consecutive day pe-

 

 

riod.

 

–

Enclose the application fee (check, cashier’s check or money order) payable to the county licensing authority

 

 

identified on Page 1.

SECTION 3

–

The municipality where the organization’s licensed premise is physically located.

SECTION 4 - 8 –

Enter specific information regarding the organization. Enter in Section 5 the type of organization applying for

 

 

license: charitable organization, religious organization, civic and service association, club, fraternal organization

 

 

and veteran’s organization, etc. If your organization qualifies as more than one type list all that applies. If

 

 

you qualify as a club you must provide the information in 4a and 4b.

SECTION 9

–

Generally, if an eligible organization owns or leases a premises as its normal business or operating site, that

 

 

premises shall be the licensed premise for purposes of operating games of chance. If an eligible organization

 

 

does not own or lease a premises upon which normal business or operations is conducted, it may, by agreement,

 

 

use the licensed premises of another licensed eligible organization or make other arrangements for a licensed

 

 

premises. Leases for licensed premiseses must be in writing.

A.– The organization must provide the address of the physical location where normal business operations are conducted. Typically this will be the organization's mailing address and/or licensed premises, and it may be indicated as such by marking the boxes in B and C.

–If no normal place of business, enter NONE.

B.– If the organization has a different mailing address than the address provided in A (such as a Post Office Box), the organization must provide the mailing address in this item.

C.– If an organization does not own or lease a normal business or operating site, has a normal business operating site with multiple structures or has multiple business or operating sites, it must indicate in this section the lo- cation it will use as its premises for conducting games of chance.

–Information on this line is required for a complete application.

SECTION 10

–

Indicate the eligible organization’s hours of operation, dates or days of week and times games are to be played.

 

–

Operating day - The period of time during any 24-hour period when an eligible organization conducts its normal

 

 

activities or holds itself open to its members.

 

–

Nonoperating day - A period of time equivalent to an eligible organization’s operating day except that the

 

 

eligible organization is closed to normal activities or to its members during that period of time.

 

–

Operating week - Seven consecutive operating days or nonoperating days.

SECTION 11

–

The executive officer or secretary of an organization must certify statements A through E by completing the

 

 

personal data required in Section 11 and by signing the application.

SECTION 12

–

Application must be notarized.

Complete the schedule sheet and enclose other documents listed at the bottom of Page 2 of the application. Social Security numbers are optional.

Forward the application, payment and other related documents to the licensing authority to obtain your license to conduct and operate games of chance.

Page 4

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