Bingo Change of Play Form
KANSAS DEPARTMENT OF REVENUE
Charitable Gaming
Docking State Office Building
915 SW Harrison Street
Topeka, Kansas 66612-1588
Phone: 785-368-8222 Facsimile: 785-296-4993
Website: http://ksrevenue.org/bustaxtypesbingo.html
License number: ____________________________
Name of Organization: __________________________________
Check mark the appropriate listing and complete the change.
Change:
____ Date of play from ___________________ to ____________________
(date)
(date)
____ Time of play from ___________________ to ____________________
(time)
(time)
____ Location of play from ___________________ to ___________________
(parlor number)
(parlor number)
or
____ Location of play from ___________________ to ___________________
(for organizations not playing at a parlor record address)
____ Cancel date(s) of play on __________________
to __________________
____ Add additional date(s) of play on ______________________
to ____________________
Location ______________________________________________
This change is: Permanent ______
Temporary ______
Signature ________________________________________________________ Position with Organization:_____________
Date: _____________________
K.A.R. 92-23-14 (b) Whenever a licensee intends to conduct bingo games on a date or at a time different from that previously
furnished in writing to the secretary of revenue, the licensee shall submit written notice of the change to the bingo enforcement
unit of the department of revenue at least seven days prior to the effective date of that change. (KSA 79-4706)
This form must be either mailed, faxed or emailed to the Office of Charitable Gaming seven days prior to any schedule changes.
BI-10
(Rev. 2-16)