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Video Gaming License Renewal Affidavit
Note that this affidavit is applicable to current licensees whose information and statements contained in their last approved application have not changed. If an unapproved change has occurred, please notify the City Clerk Department at cityclerk@cityblm.org immediately.

Below is a list of the document(s) that are required in order for your renewal to be considered complete.

Required Documentation
The following are required to be submitted by all licensees looking to renew their current license(s).
  1. Affidavit of License Renewal - By signing the affidavit, the representative verifies that no significant changes have been made to the business operations or premises.
  2. Priority Contacts and Ownership Details Form for Current Licensees. The form can be completed by clicking here.
  3. Gross Revenue Reporting Form — This form lets businesses report their total gross revenue for the previous calendar year (January 1–December 31). If needed, the City may request additional financial details to verify the information provided, and may audit these records when necessarry.
    1. NOTE: For months where no video gaming license was held or operated, please report $0 income for all categories.
    2. NOTE: If you are completing this revenue form, you DO NOT have to complete a separate one for liquor license renewal.
  5. For Fraternal and Veteran Organizations Only - Proof of status must be included with the renewal in the form of one of the following: U.S. Form 990-EZ, Certificate of Exemption, 501(c)(3), 501(c)(4), 501(c)(5), 501(c)(8), 501(c)(10), or 501(c)(19).
  6. For Regular and Large Truck Stops Only - Documentation must be included with the renewal that shows the retail sales of more than 10,000 (Regular)/50,000 (Large) gallons of diesel or biodiesel fuel per month for the past 12 months.
Additional Requirements
The following are required in order for renewal to be considered, but documentation is checked internally so there is no submission requirement unless specifically requested.

Doing Business As (DBA)/Assumed Name Registration
DBA/Assumed Names are required to be Registered if the Public-Facing Name is not an exact match to the Legal Entity Name (Example: If ABC Biz, LLC uses the name ABC Pizza with the public, then ABC Pizza must be registered. If ABC Pizza, LLC uses the name ABC Pizza, no need to be registered.)
To register your DBA/Assumed Name. You can find registration information at:
  1. State of Illinois – Assumed Name Registration (Corporations and LLCs); or
  2. McLean County – Doing Business As (DBA)/Assumed Name Registration
All Licensed Entities must be in Good Standing with the State of IL
All entities holding a license must remain in good standing with the State of Illinois. Note that this requirement does not apply to those who are not classified as entities with the State of Illinois.

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All documents can be uploaded by clicking the paperclip on the top-left of the form.
Please check that you agree before continuing.
By continuing, I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored. I agree that I am authorized to electronically sign on behalf of the business applying for renewal.
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Signature HereClick to Sign
Your Name HereClick to Sign
04/15/2026Click to Sign
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Signature HereCity Clerk Designee Will Sign Here
04/15/2026
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04/15/2026
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Additional Signatures Required

Upload Attachment(s)

Please upload the following attachments only if they have expired or are set to expire prior to the end of the renewal period (05/01). There is a 250MB limit on each attachment.

For Fraternal and Veteran Organizations Only - Proof of Status Click Here to Upload
For Regular and Large Truck Stops Only - Documentation showing gallons Click Here to Upload
Updated Floor Plan, if applicable Click Here to Upload