Form 50b - Nebraska Application For Commercial Lessor Of A Bingo Premises

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Nebraska Application for Commercial Lessor of a Bingo Premises

FORM

• Incomplete applications will be returned.

50B

• Attach

Nebraska Schedule I – Registration of a Bingo

Premises.

1 Do you hold or have you previously held a Nebraska ID number?

PLEASE DO NOT WRITE IN THIS SPACE

YES

If Yes, give number

PRINT FORM

RESET FORM

2 Federal Employer ID or Social Security Number

3 County of Business Location in Nebraska

BUSINESS NAME AND LOCATION ADDRESS

BUSINESS NAME AND MAILING ADDRESS (If different from Location.)

Name

Street Address

Street or Other Mailing Address

City

State

Zip Code

City

State

Zip Code

4 Type of Ownership

5 Type of Application

Sole Proprietorship

Domestic Corporation

Limited Liability Company (LLC)

Cancel

New

Renewal

Partnership

Foreign Corporation

Other __________________

Report Changes

Nonprofit Corporation or

(Complete only changed information

Domesticated Corporation

Organization

and provide appropriate signatures.)

6 If the applicant is a corporation or LLC, under the laws of

7 Out-of-state applicants, which are not corporations or LLC, must designate an individual at least 19 years of

age, who is a resident of, and living in, Nebraska as a resident agent.

which state has it been formed?

Name

Telephone Number

All foreign corporations and LLC must be registered

with the Secretary of State’s Office. Attach a copy of

Address

the document verifying registration with the Nebraska

Secretary of State’s Office.

City

State

Zip Code

8 List the Social Security number, full name, home address, date of birth, type of involvement, and percentage of ownership for each of the following persons involved with the applicant:

(a) If a sole proprietorship, list the individual owner;

(b) If a partnership, list each partner and spouse;

(c) If a corporation, list each officer and spouse and each person holding 10% or more of the debt or equity of the applicant corporation. If any person holding 10% or more

of the debt or equity of the applicant corporation is a partnership, LLC, or corporation, list each partner of the partnership, each member of the LLC, or each officer of the

corporation and every person holding 10% or more of the debt or equity of the partnership, LLC, or corporation;

(d) If an LLC, list each member and spouse; or

(e) If a nonprofit organization or nonprofit corporation, list each officer and the individual designated as manager.

(Attach a separate list if more space is required.)

Your Social Security number and date of birth are required under the

Nebraska Bingo

Act, and will be used to request criminal history

information from law enforcement agencies to determine if the legal requirements for a commercial lessor’s license are met.

Type of Involvement and

Social Security Number

Name, Address, City, State, Zip Code

Date of Birth

Percentage of Ownership

9 Does any person other than those listed in section 8 have any ownership interest in the business named in the license application? (See instructions.)

YES

If Yes, in the case of an individual, identify the Social Security number, full name, home address, date of birth, and type of ownership interest

of each individual. In the case of a business, identify the federal employer ID number, business name, address, and type of ownership

interest of each business. Attach additional sheets, if necessary.

Social Security Number

Name, Address, City, State, Zip Code

Date of Birth

Type of Ownership Interest

10 Is the individual or business named in this application, the owner of the premises for which the commercial lessor's license is required?

YES

If No, list the Social Security number, full name, address, date of birth, type of involvement, and percentage of ownership of each individual

who has an ownership interest in the premises. Attach copies of all lease and sublease agreements with the owner of the premises.