Pennsylvania Application for Small Games of Chance - Licensing of Distributors and Registration of Manufacturers

Application for Small Games of Chance - Licensing of Distributors and Registration of Manufacturers
Application for Small Games of Chance - Licensing of Distributors and Registration of Manufacturers (REV-1753)
IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
(SU) 12-21

REV-1753

OFFICIAL USE ONLY

APPLICATION FOR
SMALL GAMES OF CHANCE
LICENSING OF DISTRIBUTORS AND
REGISTRATION OF MANUFACTURERS

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➜

SECTION I

ACCOUNT NUMBER:
DISTRIBUTOR

-D-

MANUFACTURER

-M-

APPLICATION INFORMATION
Annual Application

Initial Application

Change of Data (attach appropriate statements)
FEE

EXPLANATION

Distributor License

$2,000

Required for initial and every annual application.

Manufacturer Registration Certificate

$2,000

Required for initial and every annual application.

Replacement Certificate or License

$100

Issued only if original is defaced, destroyed or lost.

Background Investigation for (

Individuals X $22) =

$

Every application (initial and annual) must include
a $22 Background Investigation fee for each
individual listed on Schedule A. Indicate number of
individuals listed and total background fee due.

Total Amount Remitted:

$

TYPE OF APPLICATION

If the department denies an application, a $100 application processing fee will be retained by the department. The remaining fee will be returned
to applicant. No part of the registration or license fee shall be subject to proration. No investigation fee will be refunded.

SECTION II

DISTRIBUTOR’S LICENSE INFORMATION

If applying for a distributor’s license number, complete the following information.
Legal Business Name

Telephone Number

DBA/Trade Name

Physical Street Address (PO Box is not acceptable)

City

State

ZIP Code

Mailing Address (if different from above)

City

State

ZIP Code

Revenue ID

PA Withholding Account Number

Unemployment Compensation Account Number

FEIN

Email

Sales and Use Tax License Number

SECTION III

MANUFACTURER’S REGISTRATION INFORMATION

If applying for a manufacturer’s registration number, complete the following information.
DBA/Trade Name

Legal Business Name

Telephone Number

Physical Street Address (PO Box is not acceptable)

City

State

ZIP Code

Mailing Address (if different from above)

City

State

ZIP Code

Revenue ID

PA Withholding Account Number

Unemployment Compensation Account Number

FEIN

Email

Sales and Use Tax License Number

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REV-1753 (SU) 12-21

SECTION IV

RESIDENT DESIGNEE

A person applying for a manufacturer's certificate or distributor's license under the act is required to designate a person and location within the Commonwealth for purposes of service of process.
Signature

Name of Resident Designee (Individual or Business)

PLEASE SIGN AFTER PRINTING
PA Residential Address

SECTION V

City

State

ZIP Code

CERTIFICATION

I certify that the following tax statements are true and correct: (check all that apply)
The applicant has paid all PA state taxes that are due and owing as of the date of the application.
The applicant has filed all PA state tax reports and returns due as of the date of the application.
The applicant has paid all PA state taxes that are due and owing as of the date of the application except for tax liabilities that are subject to a timely
administrative or judicial appeal (provide the assessment and docket number for the liabilities under appeal).
The applicant has paid all PA state taxes that are due and owing as of the date of the application except for tax liabilities that are subject to a duly
approved and current payment plan (copy of payment plan(s) enclosed).
The applicant’s officers, directors and persons in a supervisory or management position or employees eligible to make sales:
(i) have not been convicted of a felony in a state or federal court within the past five years.
(ii) have not been convicted within ten years of the date of application in a state or federal court of a violation of the Bingo Law or Local Option
Small Games of Chance Act or a gambling-related offense under Title 4 or Title 18 of the Pennsylvania Consolidated Statues or other comparable
state or federal law.
(iii) have not been rejected in any state for a distributor’s license or manufacturer’s certificate, or equivalent thereto.

SECTION VI

SIGNATURE

I declare that I have examined this application and instructions, including schedules and accompanying statements, and to the best of my
knowledge and belief it is true, correct and complete. The above statements are being made pursuant to the penalties for unsworn falsification
under 18 Pa.C.S. 4904.
Signature

Print Name

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Date

PLEASE SIGN AFTER PRINTING

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REV-1753 (SU) 12-21

SMALL GAMES OF CHANCE SCHEDULES
Please specify which type of applicant you are:

Manufacturer

Distributor

Legal Business Name

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

I hereby attest to the fact that the by-law and corporate officer(s) have not changed since the last application. (If checked, you do not need
to complete Schedule A.)
Name

Title/Relationship

SSN

Address

City

State

Date of Birth MM/DD/YYYY

Email

Telephone Number

Name

Title/Relationship

SSN

Address

City

State

Date of Birth MM/DD/YYYY

ZIP Code

Email

ZIP Code

Telephone Number

SCHEDULE B
List all individuals, including owners, partners, officers, directors and sales personnel responsible for taking orders and making sales of small games of
chance merchandise. If an individual resides in Pennsylvania, check whether commissioned or salaried.

Address
Date of Birth MM/DD/YYYY

City

State

Email

Commissioned
Salaried
ZIP Code

Telephone Number
SSN

Title/Relationship

Name
Address
Date of Birth MM/DD/YYYY

SSN

Title/Relationship

Name

City

State

Email

Commissioned
Salaried
ZIP Code

Telephone Number

SCHEDULE C
To be completed by distributors only. List all manufacturers with whom distributor does business regarding small games of chance.
Telephone Number

Title

Name
Address

Manufacturer’s Certificate Number

City
Telephone Number

Title

Name
Address

State

ZIP Code

Manufacturer’s Certificate Number

City

State

ZIP Code

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REV-1753 (SU) 12-21

SMALL GAMES OF CHANCE SCHEDULES (continued)
SCHEDULE D
List all states wherein business is conducted regarding small games of chance. Attach a seperate sheet if more space is required.

SCHEDULE E
Check all types of games distributed and manufactured:

Daily/Weekly Drawings

Pull-Tabs

Punchboards

Raffles

Race Night

Pools

50/50 Drawings

Dispensing Devices

Check all types of entities small games of chance will be sold to:

Eligible Organizations

Club Licensees

Taverns

Manufacturers must submit all pull-tab games, punchboards and dispensing machines to be reviewed and approved.
● For games that the department previously has approved, provide a list of the games to be manufactured for sale in the commonwealth during the
registration term. The list shall include the name of the game and form number.
● If a manufacturer is discontinuing the sale of previously approved game(s), the manufacturer shall submit a list of the game(s). The list shall contain
the name of the game and form number.
● For new games that the department has not previously approved, attach a game approval form (REV-915) for each game.
Attach a separate sheet if more space is required.
FORM #

NAME OF GAME

NEW OR DISCONTINUED
New

Discontinued

New

Discontinued

New

Discontinued

New

Discontinued

New

Discontinued

New

Discontinued

New

Discontinued

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Instructions for REV-1753

Application For Small Games of Chance

REV-1753 IN (SU) 12-21

GENERAL INFORMATION
Enclose the following items with this application:
1. Logo used by manufacturer.
2. Check, cashier’s check or money order made
payable to the PA Department of Revenue in the
amount of the total application fees.
3. Copy of Fictitious Name Registration Form,
Department of State Registry Statement or other
similar registration. Out-of-state corporations are
required to submit a copy of Certificate of Authority.
4. All appropriate schedules:
a. Schedule A - List of all owner, partners or if
incorporated, officers, directors or shareholders
controlling 10 percent (10%) or more
outstanding stock.
b. Schedule B - List of all distributor’s or
manufacturer’s representatives.
c. Schedule C - List of all small game
manufacturers with whom distributors do
business.
d. Schedule D - List of all states wherein business
is conducted regarding small games of chance.
e. Schedule E - List of all approved small games
of chance.
5. Copy of constitution- and by-laws or corporate
charter (required for initial applications or when data
changes).
The Department of Revenue must be notified of changes to
the information included on the application.
HOW TO OBTAIN FORMS
To request additional copies of the REV-1753:
● Visit our web site at www.revenue.pa.gov, or:
● Call our toll-free 24-hour Forms Ordering Message
Service at 1-800-362-2050.
ADDITIONAL QUESTIONS
Questions pertaining to Small Games of Chance and this
application can be referred to [email protected] or the
address below.

LINE INSTRUCTIONS

Check the box to indicate the type of application. If
Background Investigation is checked, print or type the
number of individuals. Multiply this number by $22 to
determine the fee.
Print or type the total amount to be remitted to the department.

SECTION II
DISTRIBUTOR’S LICENSE INFORAMTION
Print or type the Business Name, DBA/Trade Name,
Telephone Number, Address, City, State, Zip Code, Revenue
ID, PA Withholding Account Number, Unemployment
Compensation Account Number, FEIN, Email and Sales and
Use Tax License Number.

SECTION III
MANUFACTURER’S REGISTRATION INFORMATION
Print or type the Business Name, DBA/Trade Name,
Telephone Number, Address, City, State, Zip Code, Revenue
ID, PA Withholding Account Number, Unemployment
Compensation Account Number, FEIN, Email and Sales and
Use Tax License Number.

SECTION IV
RESIDENT DESIGNEE
Print or type the Name, Address, City, State and Zip Code.
The resident designee must sign this section.

SECTION V
CERTIFICATION
Check all tax statements that apply.

SECTION VI
SIGNATURE
Print name, sign by officer of entity and date.
Mail the application, other documents and check or money
order to:
PA DEPARTMENT OF REVENUE
PO BOX 280906
HARRISBURG, PA 17128-0906

SECTION I
Check the box to indicate the type of application.
www.revenue.pa.gov
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