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City of Bloomington, Illinois

cityclerk@cityblm.org

115 E. Washington St., Bloomington, IL, 61701, US

309-434-2509

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Video Gaming License Renewal Gross Income Report
This document is required as a supplement to the establishment's Video Gaming License Renewal Affidavit. If you have not completed the Affidavit, you can do so by clicking here.

The Gross Income Report must be completed on the provided form. Documents received on different forms will not be accepted.

This form will be used by the establishment to provide data from the previous calendar year (January to December). Establishments must provide gross income reports, detailed by category of revenue generated on a per-month basis and showing the percentage of gaming revenue generated by the establishment.

FOR MONTHS WHERE NO VIDEO GAMING LICENSE WAS HELD OR OPERATED, PLEASE REPORT $0 INCOME FOR ALL CATEGORIES.

NOTE: Additional financial details of said gross revenues shall be made available upon request by the City.

In addition to Video Gaming and Alcohol, categories of income may include food, merchandise sales, etc. NOTE: Each establishment may have different categories. All categories of income must be included as separate items.
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11/15/2024Click to Sign
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11/15/2024

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