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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 Affidavit

Below is a list of the document(s) that are required at the time of submission. If the required documents are not submitted with the renewal, the form will be sent back to the submitter.
  1. Affidavit of License Renewal (Next page) - By signing the affidavit, the representative verifies that no significant changes have been made to the business operations or premises while having the opportunity to update minor changes.
  2. For Fraternal and Veteran Organizations Only: Proof of status has been 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).
  3. For Regular and Large Truck Stops Only: documentation has been 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.
To be Submitted Separately:
  1. Gross Income Report - Must be completed on the provided form, which can be found here. All categories of income must be included as separate items.
Conditional Requirements:
  • State of Illinois Video Gaming License - License must be active through the start of the license term.
  • Updated Floor Plan - if changes have been made in the past 12 months.
  • Updated Lease Agreement for the licensed premises - if the lease has expired or is expiring before the license term
  • Assumed Name/DBA must be registered with the State of IL or McLean County – If already registered, this documentation is not required for submission and will be monitored internally. If not registered, please complete one of the following:
  • Corporations and Limited Liability Companies Only - Must be in Good Standing with the State of IL. This documentation is not required for submission and will be monitored internally.

All documents can be uploaded after the signature of the affidavit.
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.
11/15/2024Click to Sign
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11/15/2024

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State of IL Video Gaming License - License must be active through the start of the license term Click Here to Upload
Updated Floor Plan - if changes have been made in the past 12 months Click Here to Upload
Updated Lease Agreement for the licensed premises - if the lease has expired or is expiring before the license term ***If premise is owned, disregard Click Here to Upload
For Fraternal and Veteran Organizations Only: Proof of status has been 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). Click Here to Upload
For Regular and Large Truck Stops Only: documentation has been 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. Click Here to Upload
Assumed Name/DBA must be registered with the State of IL or McLean County – If already registered, this documentation is not required for submission and will be monitored internally. Click Here to Upload