Form 50 - Nebraska Application For Bingo, Lottery, Raffle, Or Lottery By Pickle Card

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Nebraska Application
Form
for Bingo, Lottery, Raffle, or Lottery by Pickle Card
50
Incomplete applications will be returned.
Please Do Not Write in This Space
PRINT FORM
RESET FORM
3 County of Organization’s Location in Nebraska
1 Do you hold or have you previously held a Nebraska ID Number?
2 Federal Employer ID Number
If yes, provide the number
YES
NO
Organization’s Name and Location Address
Organization’s Name and Mailing Address
Name
Name
Street Address
Mailing Address
City
State
Zip Code
City
State
Zip Code
5 Type of License (check all that apply)
6 Type of Application
Lottery/Raffle — $30 Fee
(Attach Form 50H and Supplemental Questionnaire)
Bingo Class I — $30 Fee
New — Complete Entire Application
Lottery/Raffle Special Permits — $10 Fee for Each Permit
(Attach Form 50H and Schedule I, Form 50)
(Attach articles of incorporation
Organizations applying for a special permit must also apply
and bylaws)
Bingo Class II — $100 Fee
for or hold a lottery/raffle license.
(Attach Form 50H, Form 50C, and Schedule I, Form 50)
Report Changes
Special Permit Dates (See instructions)
Lottery by Pickle Card Class I — $200 Fee
First 12-month period:
(Attach Form 50H)
Upgrade License from Class I to II
Beginning__________, 20___ and ending_________, 20___
Lottery by Pickle Card Class II — $300 Fee
Second 12-month period:
Cancel (Return license)
(Attach Form 50H, Form 50E, and Schedule II, Form 50)
Beginning__________, 20___ and ending_________, 20___
7 Type of Organization (Check all that apply)
8 Are you organized or incorporated in Nebraska?
Nonprofit Organization
Nonprofit Corporation
Volunteer Fire Company or
YES
NO
Volunteer First-Aid, Rescue
Other
Ambulance, or Emergency Squad
Indicate year organized
9 Is your organization currently exempt under Section 501 of the Internal Revenue Code?
10 Number of Members
Submit a current copy of your organization’s bylaws, articles of incorporation, or
YES
NO
If Yes, indicate subsection: 501(c)
other written document in which membership is defined.
Attach a copy of the exemption determination letter issued to your organization by the
IRS or a copy of the page of the Official Catholic Directory where your organization’s
Are all members and players 60 years and older (for bingo applicants only)?
name appears. If your organization is exempt under a Group Ruling issued by the IRS,
indicate the Group Exemption Number (see instructions for line 9 on reverse side).
YES
NO
11 Is your organization affiliated with a state or national organization?
Phone Number
YES
NO
If Yes, enter name and address
Name
Address
City
State
Zip Code
12 Identify Separate Bank Accounts to be Maintained for Each Gaming Activity
Account Number
Name, Address, City, State, Zip Code of Financial Institution
Bingo
Pickle
Lottery/Raffle
13 Name and Address of Designated Premises (for pickle card applicants only):
Name
Address
City
State
Zip Code
14 Description of the Designated Premises Indicated on Line 13 (Attach Additional Sheet if Necessary):
15 Identify Officers (Attach additional list, if necessary) (Must provide at least three)
Date of
Title
Social Security Number (Optional)
Birth
Name, Address, City, State, Zip Code
16 Person to contact regarding this application
Name
Title
Daytime Phone Number
Under penalties of law, I declare that I have examined this application, 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, the Nebraska Pickle Card Lottery Act, the Nebraska Lottery and Raffle Act, and the regulations adopted under such Acts.
sign
here
Officer Listed in Line 15 or Person Authorized by Attached Power of Attorney
Title
Date
Daytime Phone Number
If applying for a bingo license, mail a copy of this application to the city or county clerk.
Mail the original application and any fees to: Nebraska Dept of Revenue, Charitable Gaming Division, PO Box 94855, Lincoln, NE 68509-4855.
Visit our website at revenue.ne.gov/gaming.
9-189-2001 Rev.
Supersedes 9-189-2001 Rev. 5-2008
Retain a copy for your records.
10-2013

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