VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL SPECIAL EVENT LICENSE APPLICATION ADDENDUM NOTICE TO SPECIAL EVENT LICENSES APPLICANTS Board regulations require persons in charge of public events to report to the Board the income and expenses associated with the event, when the licensee engages another person to organize, conduct or operate the event on behalf of the licensee. The purpose of this form is to determine whether a report of income and expenses will be required in connection with the license applied for. Applicant name ______________________________________ Date of event__________________ SAME AS APPEARS ON SPECIAL EVENT LICENSE APPLICATION Organization _________________________________________ License #____________________ NAME OF NONPROFIT ORGANIZATION OBTAINING LICENSE Address_____________________________________________Telephone____________________ City____________________________________State__________________Zip_________________ Please answer the following questions: 1. Will any person, organization, or business, other than the nonprofit organization applying for this license, receive any compensation or payment for organizing, operating, or conducting the event for which this license is requested? [ ] YES [ ] NO 2. If the answer to question 1 is YES, will alcoholic beverages be sold to members of the general public? [ ] YES [ ] NO Applicant signature_________________________________________Date____________________ ATTACH THIS ADDENDUM TO THE SPECIAL EVENT LICENSE APPLICATION If the answer to both questions 1 and 2 is YES, the applicant must (1) attach to the application a copy of any agreement between the licensee and the person engaged to organize, operate, or conduct the event, and (2) if the license issued, complete a Statement of Income and Expenses for Special Event Licenses form provided with the license and return the completed form to the issuing regional office within thirty (30) days after the date of the event. VA ABC Abingdon 545 W. Main St. Abingdon, VA 24210 (276) 676-5502 VA ABC Alexandria 6308 Grovedale Dr. Alexandria, VA 22310 (703) 313-4432 VA ABC Chesapeake 1103 S. Military Hwy. Chesapeake, VA 23320 (757) 424-6700 VA ABC Hampton 4907 W. Mercury Blvd. Hampton, VA 23666 (757) 825-7830 VA ABC Richmond North 2901 Hermitage Rd. Richmond, VA 23220 (804) 213-4620 VA ABC Richmond South 2901 Hermitage Rd. Richmond, VA 23220 (804) 213-4624 VA ABC Roanoke 201 Compton St. Roanoke, VA 24012 (540) 857-6565 VA ABC Staunton/ Charlottesville 460 Commerce Square Staunton, VA 24401 (540) 332-7800 Form SE-1 VA ABC Lynchburg 20353 Timberlake Rd. Lynchburg, VA 24502 (434) 582-5136 Rev. 08/02 American LegalNet, Inc. www.FormsWorkflow.com VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL BUREAU OF LAW ENFORCEMENT OPERATIONS Statement of Income & Expenses for Special Event Licenses Name of Organization or Group Street Address City, State, Zip County EIN# ABC License No VA Sales Tax No. Contact Name Phone # Fax# For the event held on ______________________ (Must be returned within 30 days of the event) Receipts: Food & Other Merchandise Sales Alcoholic Beverage Sales Admissions Other Sources of Receipts: Total Receipts Operating Expenses: Advertising Salaries and Wages Purchases of Food & Other Merchandise Purchases of Alcoholic Beverages Purchases of Other Items Rent Taxes, Licenses, and etc. Other Expenses Total Operating Expenses Total Funds Available for Contributions: Total Funds Contributed: Total Funds Not Contributed: Certification I certify that this report and the accompanying schedules have been examined by me and to the best of my knowledge and belief are complete, true and accurate. _______________________________________________________________________________ Signature Title Print Name Date Form SE-2 Rev. 8/02 VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL BUREAU OF LAW ENFORCEMENT OPERATIONS Statement of Income & Expenses for Special Event Licenses INSTRUCTIONS Step 1 Complete all organizational information where possible. Be sure to include the name of a contact person with their day time phone number. Step 2 “For the event held ____ ” Fill out a different statement for each event, normally this will be one day only. If the event was for multiple days enter the beginning and ending date. For organizations having a one-day event each week for several months each event shall be listed separately. Step 3 Receipts: Total dollar amount should be entered for each category. Food & Other Merchandise Sales = All Sales except Alcoholic Beverage Sales Alcoholic Beverage Sales = Same Admissions = Ticket sales, Admission or Cover Charges Other Sources of Receipts = All other income to include items such as; sponsorships (alcohol related sponsors and all other), parking fees, etc. If the organization received one amount of money but has multiple events during the season, divide the amount by the number of events and include the per event amount on the form. Step 4 Total the Receipts and enter the amount in the space provided. Step 5 Operating Expenses: Total dollar amount should be entered for each category. Advertising = all advertising to include radio, TV, flyers, banners and etc. paid for by the organization. Advertisements for the whole season should be divided by the number of events and include the per event amount. Salaries and Wages = Each person working for the organization, receiving payment for work relating to this event (i.e. working the event or working prior to or after the event). If a person receives a ‘salary’ for the entire season, divide the total amount by the number of events and include the per event amount. Purchases of Food & Other Merchandise = Items for resale only - Does not include alcoholic beverages. Purchases of Alcoholic Beverages = alcoholic beverages only Purchase of Other Items = This section would include all items purchased not previously accounted for, such as; paper products, tables, tents and etc. Rent = All items rented or leased for this event, such as; port-o-lets, stages, sound equipment, event location, etc. Items rented or leased for the season should be divided by the number of events and include the per event amount. Taxes, Licenses, etc.= Includes items such as; sales tax, ABC license, business license, etc. Other Expenses = This section includes all other expenses of the event not already accounted for, such as; bands, promoters, security, office expenses or administrative expenses. Expenses that cover the whole season should be divided by the number of events and include the per event amount. Step 6 Total the Expenses and enter the amount in the space provided. Step 7 Total Funds Available for Contributions = Subtract the Operating Expenses from the Receipts and enter the amount in the space provided. Step 8 Total Funds Contributed = Enter the actual dollar amount contributed to a non profit organization. Do not list contributions that have not yet occurred. Step 9 Total Funds Not Contributed = All funds remaining that are being retained by the organization obtaining the license. Step10 Return completed form to the issuing regional office within 30 days after the date of the event. Form SE-2 Instructions Revised 8/02