Form 50g - Nebraska Schedule Ii - County/city Lottery Sales

Download a blank fillable Form 50g - Nebraska Schedule Ii - County/city Lottery Sales in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 50g - Nebraska Schedule Ii - County/city Lottery Sales with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

NEBRASKA SCHEDULE II – County/City Lottery Sales

– County/City Lottery Sales

FORM

Outlet Location Application

• No license fee required

50G

• Incomplete schedules will be returned

• Read instructions on reverse side

PLEASE DO NOT WRITE IN THIS SPACE

RESET FORM

County, City, or Village Name as shown on

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

Form 50G

SALES OUTLET LOCATION 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 sales outlet location’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

Name

Business Name

Trade Name of Business (If Different Than Above)

Street or Other Mailing Address

City

State

Zip Code

Street Address

City

State

Zip Code

County

Nebraska Liquor License Number

6 Type of Ownership

Location Type

Sole Proprietorship

Domestic Corporation

Limited Liability Company

Nonproﬁt Corporation or Organization

Keno Satellite

Partnership

Foreign Corporation

Domesticated Corporation

Other _________________

Keno Independent Game

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 person 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.

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

(Attach additional sheet if necessary)

Type of Involvement and

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

Date of Birth

Social Security Number

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

If Yes, 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)

10a Has anyone listed in line 8 ever been convicted of, forfeited bond upon a charge of, or

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

pled guilty or nolo contendere to any felony or misdemeanor at any time involving any

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

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

gambling activity, fraud, theft, willful failure to make required payments or reports, or

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

ﬁling false reports with a governmental agency at any level? This includes shoplifting or

Lottery Act?

issuing bad checks.

YES

If Yes, see instructions.

YES

If Yes, attach a detailed explanation of such interests.

10b Has anyone listed in line 8 ever been convicted of, forfeited bond upon a charge of, or

pled guilty or nolo contendere to any felony other than that described in line 10a within

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

ten years preceding the date of this application?

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

YES

If Yes, see instructions.

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

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

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

YES

If Yes, attach a detailed explanation of such interests.

applicable, attached a signed afﬁdavit for each spouse waiver?

YES

(See instructions)

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

sign

(

)

here

Daytime Telephone Number

Signature of Sales Outlet Location Owner, Member, Partner,

Date

Title

Ofﬁcer, or Person Authorized by Attached Power of Attorney

Name of Person to Contact Regarding This Application:

(

)

Name

Title

Daytime Telephone Number

AUTHORIZATION – Signature of Governing Ofﬁcial

Attach documentation indicating approval of location by governing board of the county, city or village and a copy of the site agreement.

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

Title

Date

Daytime Telephone Number

Mail the original application to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, P.O. BOX 94855, LINCOLN, NE 68509-4855

Please make a copy for your records.

9-132-1993 Rev. 6-2007 Supersedes 9-132-1993 Rev. 6-2006