Form 50g - Nebraska Schedule I - County/city Lottery Operator Application

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NEBRASKA SCHEDULE I – County/City Lottery Operator

FORM

Application

• Include license fee of $500

50G

• Incomplete schedules will be returned

• Read instructions on reverse side

PLEASE DO NOT WRITE IN THIS SPACE

RESET FORM

1 Nebraska I.D. Number of County, City, or Village

County, City, or Village Name as shown on

Form 50G

LOTTERY OPERATOR INFORMATION (Attach additional sheet if necessary)

Your social security number and date of birth are required under the Nebraska County and City Lottery Act and will be used to request criminal history information

from law enforcement agencies to determine if the legal requirements for a lottery operator’s license are met.

3 Nebraska Identiﬁcation Number

4 Federal I.D. or Social Security Number

5 Type of Application:

New

Renewal

Report Changes

Cancel

BUSINESS NAME AND LOCATION ADDRESS

BUSINESS NAME AND MAILING ADDRESS

Business Name

Name

Street or Other Mailing Address

Trade Name of Business (If Different Than Above)

Street Address

City

State

Zip Code

City

State

Zip Code

County

6 Type of Ownership

If the applicant is a corporation, limited liability company,

or partnership, under the laws of what state has it been

Other

Sole Proprietorship

Domestic Corporation

Limited Liability Company

incorporated, formed, or organized?

Partnership

Foreign Corporation

Domesticated Corporation

Each applicant for a license as a lottery operator is subject to a background investigation and/or an inspection of its facilities. The Department may require the

applicant to pay the actual costs incurred in conducting such investigation or inspection.

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 ten percent or more of the debt or equity of the applicant corporation. If any entity holding ten percent

or more of the debt or equity of the applicant corporation is a partnership, limited liability company, or corporation, list each partner of such partnership, each member of such

limited liability company, or each ofﬁcer of such corporation and every person holding ten percent or more of the debt or equity of any such partnership, limited liability company

or corporation.

d. If a limited liability company, list each member and spouse.

(Attach additional sheet if necessary)

Type of Involvement and

Social Security Number

Name, Address, City, State, Zip Code (See instructions)

Date of Birth

Percentage of Ownership

9 Does any person other than those listed in line 8 above have any ownership interest in the license applicant? (See instructions)

YES

IfYes, in the case of an individual, identify the social security number, full name, home address, date of birth, type of ownership interest of each such individual. In the case of a business,

identify the federal employer identiﬁcation number, business name, address, and type of ownership interest of each such business. (Attach additional sheet if necessary)

10 Has each of the individuals listed in line 8 above ﬁled ﬁngerprint cards and proper

11a List those individuals, if any, from line 8 above who have previously ﬁled ﬁnger-

fees for criminal background investigation with the Nebraska State Patrol, or when

print cards with the Nebraska Liquor Control Commission.

applicable, attached a signed afﬁdavit for each spouse waiver?

(See instructions)

YES

12 Has each of the individuals listed in line 8 above completed and attached a Personal

History Record, or when applicable, attached a signed afﬁdavit for each spouse

waiver?

YES

(See instructions)

11b Nebraska Liquor License Number

14 Does any member of the governing board or any governing ofﬁcial of the

13 Do any of the individuals listed in line 8 above have a ﬁnancial interest, directly or

county, city, or village named in this application have any ﬁnancial interest,

indirectly, in any company licensed as a manufacturer or distributor pursuant to the

directly or indirectly, in the business named in this application?

Nebraska Bingo Act or the Nebraska Pickle Card Lottery Act or in any company

licensed as a manufacturer-distributor pursuant to the Nebraska County and City

YES

Lottery Act?

If Yes, attach a detailed explanation of such interests.

YES

If Yes, attach a detailed explanation of such interests.

15 Do any of the individuals listed in line 8 above currently hold or have any of the individuals previously held any other licenses issued under the Nebraska Bingo Act, the

Nebraska Pickle Card Lottery Act, the Nebraska Lottery and Rafﬂe Act, or the Nebraska County and City Lottery Act?

YES

If Yes, indicate the types of licenses, and their current status (active, suspended, cancelled, revoked, or expired).

Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct. I will comply with the provisions

sign

of the Nebraska County and City Lottery Act and the regulations adopted under such Act.

(

)

here

Signature of Lottery Operator Owner, Member, Partner, Ofﬁcer,

Title

Daytime Telephone Number

Date

or Person Authorized by Attached Power of Attorney

Name of Person to Contact Regarding This Application:

Daytime Telephone Number (

)

Name

Title

Daytime Telephone Number

AUTHORIZATION – Signature of Governing Ofﬁcial

sign

I declare that I have examined this application, and authorize the applicant to conduct a lottery on behalf of the county, city, or village named in this application.

(

)

here

Authorized Signature

Date

Title

Daytime Telephone Number

Mail the original application and $500 fee to: NEBR. DEPT. OF REVENUE, CHARITABLE GAMING DIVISION, P.O. BOX 94855, LINCOLN, NE 68509-4855

Please make a copy for your records.

9-066-1989 Rev. 6-2008 Supersedes 9-066-1989 Rev. 4-2004