Form 50g - Nebraska Schedule I - County/city Lottery Operator Application Page 2
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1
2INSTRUCTIONS
WHO MUST FILE. Any individual or business that has contracted
LINE 8. Identify the social security number, name, address, date
of birth, type of involvement (owner, member, partner, offi cer,
with a county, city, or village to conduct a lottery on its behalf must
apply for and obtain a lottery operator license. A separate license is
debt or equity holder, or spouse), and percentage of ownership
required for each county, city, or village on whose behalf a lottery
of each person who has any interest in the business to be licensed
as a lottery operator.
will be conducted by the lottery operator.
WHEN AND WHERE TO FILE. All licenses issued to any
A person is a debt holder of the partnership, limited liability
lottery operator expire on May 31 of every even-numbered year
company, or corporation if such person holds any mortgages,
and may be renewed on a biennial basis. The Nebraska Schedule I
notes, bonds, convertible debentures, or other obligations, whether
- County/City Lottery Operator Application may be submitted with
written or oral, issued by the partnership, limited liability company,
the Nebraska Application for County/City Lottery, Form 50G, or
or corporation. For purposes of this application, a debt holder
submitted separately if the county, city, or village is already licensed.
does not include any fi nancial institution organized or chartered
Applications for license renewal must be submitted to the Nebraska
under the laws of Nebraska, any other state, or the United States
Department of Revenue at least 60 days prior to the expiration date
relating to banks, savings institutions, trust companies, savings
of the license. License fees are due in full for the biennial licensing
and loan associations, credit unions, installment loan licensees,
period. However, if a new license application is received by the
or similar associations organized under the laws of Nebraska
Department and the license will become effective on or after June 1
and subject to supervision by the Department of Banking and
of the second year of the biennial licensing period, the license fee to
Finance. A person is an equity holder of the partnership, limited
be remitted to the Department is one-half of the biennial fee.
liability company, or corporation if such person holds any capital
stock, whether common or preferred, or any ownership interest
The Nebraska Schedule I may also be utilized during the period
or share issued by the partnership, limited liability company, or
covered by the license to report changes in the application information
corporation.
or to cancel the license. Any changes in the information originally
submitted on the application must be provided to the Department
LINE 9. Identify any person(s) who have an ownership interest in
within 30 days of such changes.
the license applicant not listed in line 8. Owner means a person with
a right to share in the profi ts, losses, or liabilities of an applicant or
Mail the Nebraska Schedule I with the license fee of $500 and
licensee. The term includes loan guarantors who make actual debt
attachments to the Nebraska Department of Revenue, Charitable
payments for or contribute capital to a license applicant or licensee
Gaming Division, P.O. Box 94855, Lincoln, Nebraska 68509-4855.
with a contingent right to share in the profi ts, losses, or liabilities of the
Please make a copy of this application for your records. Checks written
operation. The term ownership interest is synonymous with owner.
to the Department of Revenue may be presented electronically.
SPECIFIC INSTRUCTIONS
LINES 10, 11a and 11b. Nebraska Revised Statutes, Section 9-
DEFINITION. Lottery operator is any individual, sole proprietorship,
1,104, requires all new applicants for a lottery operator license to be
limited liability company, partnership, or corporation which operates
fi ngerprinted for criminal background investigation purposes. Please
a lottery on behalf of a county, city, or village. A lottery operator is
refer to the Instructions for Completing Fingerprint Application
selected by the county, city, or village to conduct the lottery in its
to determine who is subject to this requirement. Fingerprinting of
entirety on behalf of the county, city, or village. A written contract
a spouse will be waived if an Affi davit by Spouse for Waiver of
is executed which sets forth the obligations and responsibilities of
Fingerprinting and/or Personal History Record and Background
both parties. A lottery operator typically has overall responsibility
Disclosure Form for Charitable Gaming Licensees accompanies the
for the daily operation of the lottery including, but not limited
application form. Fingerprinting may be waived for those applicants
to, responsibility and liability for all operational aspects of the
who have previously fi led fi ngerprint cards with the Nebraska Liquor
lottery which includes daily gaming operations; purchase, repair,
Control Commission. Insert your active liquor license number, if
replacement, and maintenance of lottery equipment; purchase and
applicable. Each individual required to be fi ngerprinted must submit
maintenance of lottery supplies; compensation, staffi ng, and training
two fi ngerprint cards and the proper fees directly to the Nebraska
of all employees and agents; processing and handling lottery gross
State Patrol.
proceeds; preparation of all reports required of a county, city, or village
LINE 12. Each individual required to be fi ngerprinted must also
or lottery operator by the Department or any governmental entity or
complete and attach a Personal History Record and Background
agency; advertising; development of offi cial rules and regulations for
Disclosure Form. Completion of the Personal History Record
play and collection of prizes and progressive game prizes; oversight
and Background Disclosure Form will be waived for a spouse
of the lottery operation; and all other record keeping. Generally,
if an Affi davit by Spouse for Waiver of Fingerprinting and/or
individual locations within the county, city, or village which are only
Personal History Record and Background Disclosure Form for
(1) locations where lottery tickets are sold; or (2) locations where keno
Charitable Gaming Licensees accompanies the application form.
is played, are not lottery operators, but are sales outlet locations.
Please note that a Personal History Record and Background
TYPE OF OWNERSHIP. Enter the type of ownership under
Disclosure Form is still required even though the applicant’s
which your business is operated. Partnership includes all types of
fi ngerprints were previously fi led with the Nebraska Liquor
partnerships such as general, limited, and joint ventures. A domestic
Control Commission.
corporation is a corporation which is organized under the laws of
AUTHORIZED SIGNATURES. The application must be signed by a
Nebraska and has qualifi ed to do business in this state. A foreign
lottery operator owner, member, partner, offi cer or person authorized
corporation is a corporation which is organized under the laws of
by an attached power of attorney.
another state. A domesticated corporation is a foreign corporation
COUNTY/CITY AUTHORIZATION. The application must also be
that is domesticated in Nebraska.
signed by a member of the governing board or a governing offi cial
LINE 7. If your business is a corporation, limited liability company,
of the county, city or village as an indication of county/city/village
or partnership, enter the name of the state under the laws of which
approval of the applicant to conduct the lottery on its behalf.
the business has been formed. The Nebraska County and City Lottery
Any questions regarding the completion of this application should
Act requires a lottery operator to be a resident of Nebraska or, if a
be addressed to the Nebraska Department of Revenue, Charitable
partnership, organized under the laws of Nebraska, or if a corporation,
Gaming Division, P.O. Box 94855, Lincoln, Nebraska 68509-4855,
incorporated under the Nebraska Business Corporation Act, or if
telephone (402) 471-5937 or toll free (877) 564-1315. Additional
a limited liability company, formed under the Limited Liability
information and forms may be obtained from the Department’s Web
Company Act. A nonprofi t organization or nonprofi t corporation is
site at
not eligible to obtain a lottery operator license.
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