Form 50b - Registration Of A Bingo Premises Form
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NEBRASKA SCHEDULE
— Registration of a Bingo Premises
FORM 50B
• Include registration fee of $200 for each premises.
• Incomplete schedules will be returned.
Schedule I
• Complete a separate Nebraska Schedule I for each premises to be registered.
1 Business Name as Shown on Nebraska Application for Commercial Lessor of a Bingo Premises,
PLEASE DO NOT WRITE IN THIS SPACE
Form 50B
RESET FORM
PRINT FORM
2 Nebraska ID Number
3 Reason for Filing:
New
Renewal
Report Changes (Complete only changed information and provide appropriate signatures.)
Cancel
4 Licensed Organization’s Nebraska ID Number
5 Licensed Organization’s Name
Bingo Occasions
6 Frequency
7 Days of Week
Time (From/To)
Once a week
to
Twice a week
to
Other (specify)
to
________________________
Location of This Bingo Premises
8 Street Address
Telephone Number
City
State
Zip Code
County
9 Legal Description of This Bingo Premises
10 What is the appraised value of this premises for property tax purposes?
11 What is the square footage of the space you lease for the bingo activity?
$
12 What is the seating capacity of the premises?
Premises Seating Capacity:_________________________________________
Bingo Seating Capacity: __________________________________________
13 What is the lease rate of the premises for weddings, anniversaries, and seminars?
$
If there is a difference in the amount of the lease for a bingo occasion versus a non bingo-related function, explain the reasons for the difference.
14 Is any tangible personal property included in the lease of the premises?
YES
NO
If Yes, attach an itemized list of all property including, but not limited to, bingo equipment, tables, chairs, video cameras, concession equipment, and security equipment.
15 List all services included within the premises lease and the annual cost of the service to the lessor.
Annual Cost of Service
YES
NO
Janitorial Services
$_____________________
Liability Insurance
YES
NO
$_____________________
YES
NO
Premises Insurance
$_____________________
Property Taxes
YES
NO
$_____________________
YES
NO
Security Services
$_____________________
YES
NO
Utilities
$_____________________
Other___________________
$_____________________
YES
NO
Under penalties of law, I declare that I have examined this schedule, and to the best of my knowledge and belief, it is correct and complete. I will
comply with all of the provisions of the Nebraska Bingo Act and the regulations adopted under this Act.
sign
here
Signature of Owner, Partner, Officer, Member of
Title
Date
Daytime Telephone Number
Commercial Lessor, or Person Authorized by
Attached
Power of Attorney
Email Address
Mail this original schedule and $200 fee for each bingo premises to:
NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, PO BOX 94855, LINCOLN, NE 68509-4855
revenue.nebraska.gov/gaming
RETAIN A COPY FOR YOUR RECORDS.
6-2011
9-043-1988 Rev.
Supersedes 9-043-1988 Rev. 3-2009
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