Form 50g - Nebraska Schedule Ii - County/city Lottery Sales Page 2
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1
2INSTRUCTIONS
WHO MUST FILE. Any individual, business, nonprofi t organization,
A person is a debt holder of the corporation, partnership, or limited
liability company if such person holds any mortgages, notes, bonds,
or nonprofi t corporation that has contracted with a lottery operator to
conduct a lottery on behalf of a county, city, or village must apply for
convertible debentures, or other obligations, whether written or oral,
and obtain a lottery sales outlet location license. This includes any
issued by the corporation, partnership, or limited liability company.
individual or business whose only involvement with the operation
For purposes of this application, a debt holder does not include
of the lottery is the provision of space to the lottery operator, even if
any fi nancial institution organized or chartered under the laws of
Nebraska, any other state, or the United States relating to banks,
the space is leased to and staffed by the lottery operator.
savings institutions, trust companies, savings and loan associations,
WHEN AND WHERE TO FILE. All licenses issued to any lottery
credit unions, installment loan licensees, or similar associations
sales outlet location expire on May 31 of every even-numbered year
organized under the laws of Nebraska and subject to supervision by
and may be renewed on a biennial basis. The Nebraska Schedule
the Department of Banking and Finance. A person is an equity holder
II - County/City Lottery Sales Outlet Location Application may be
of the corporation, partnership, or limited liability company if such
submitted with the Nebraska Application for County/City Lottery,
person holds any capital stock, whether common or preferred, or any
Form 50G, and the Nebraska Schedule I - County/City Lottery
ownership interest or share issued by the corporation, partnership, or
Operator Application, or submitted separately if the county, city, or
limited liability company.
village and lottery operator are already licensed. Applications for
LINE 9. Identify any person(s) who have an ownership interest in
license renewal must be submitted to the Nebraska Department of
the license applicant not listed in Line 8. Owner means a person with
Revenue at least 60 days prior to the expiration date of the license.
a right to share in the profi ts, losses, or liabilities of an applicant or
The Nebraska Schedule II may also be utilized during the period
licensee. The term includes loan guarantors who make actual debt
covered by the license to report changes in the application information
payments for or contribute capital to a license applicant or licensee
or to cancel the license. Any changes in the information originally
with a contingent right to share in the profi ts, losses, or liabilities of the
submitted on the application must be provided to the Department
operation. The term ownership interest is synonymous with owner.
within 30 days of such changes.
LINES 10a and 10b. If the “Yes,” box is checked, provide an
Mail the Nebraska Schedule II and attachments to the Nebraska
attachment with the following information, if known:
Department of Revenue, Charitable Gaming Division, P.O. Box 94855,
1.
The date and place the incident occurred.
Lincoln, Nebraska 68509-4855. Please make a copy of this application
2.
The court case or docket number under which it is fi led.
for your records.
3.
The original charge and ultimate disposition of the matter.
SPECIFIC INSTRUCTIONS
4.
A description of the events which are the subject of the
DEFINITION. Sales outlet location as it applies to keno means a
incident.
location other than the lottery operator location where keno wagers
LINE 11. Nebraska Revised Statutes, Section 9-1,104, requires all
are placed. This includes any person whose only involvement with
new applicants for a sales outlet location license to be fi ngerprinted
the operation of the lottery is the provision of space to the county,
for criminal background investigation purposes. Please refer to the
city, village, or lottery operator for a satellite location or independent
Instructions for Completing FingerprintApplication to determine
location even if the space is leased to and staffed by the county, city,
who is subject to this requirement. Fingerprinting of a spouse will
village, or lottery operator. Sales outlet location as it applies to a ticket
be waived if an Affi davit by Spouse for Waiver of Fingerprinting
drawing means a location where lottery tickets are sold.
and/or Personal History Record and Background Disclosure Form
TYPE OF OWNERSHIP. Enter the type of ownership under
for Charitable Gaming Licensees accompanies the application
which your business is operated. Partnership includes all types of
form. Fingerprinting may be waived for those applicants who have
partnerships such as general, limited, and joint ventures. A domestic
previously fi led fi ngerprint cards with the Nebraska Liquor Control
corporation is a corporation which is organized under the laws of
Commission. Each individual required to be fi ngerprinted must submit
Nebraska and has qualifi ed to do business in this state. A foreign
two fi ngerprint cards and the proper fees directly to the Nebraska
corporation is a corporation which is organized under the laws of
State Patrol.
another state. A domesticated corporation is a foreign corporation
AUTHORIZED SIGNATURES. The application must be signed
that is domesticated in Nebraska.
by a lottery sales outlet location owner, member, partner, offi cer, or
LINE 7. A keno satellite location is separate from a main keno location
person authorized by an attached power of attorney.
and electronically linked to the main location, but does not conduct its
COUNTY/CITY AUTHORIZATION. The application must also be
own winning number selection. An independent keno game location
signed by a member of the governing board or a governing offi cial
is not electronically linked to another location and does conduct its
of the county, city, or village as an indication of county/city/village
own winning number selection.
approval of the applicant to participate in the lottery on its behalf.
LINE 8. Identify the social security number, name, address, date of
Any questions regarding the completion of this application should be
birth, type of involvement (owner, member, partner, offi cer, debt or
addressed to the Nebraska Department of Revenue, Charitable Gaming
equity holder, or spouse) and percentage of ownership of each person
Division, P.O. Box 94855, Lincoln, Nebraska 68509-4855, telephone
who has any interest in the entity to be licensed as a lottery sales outlet
(402) 471-5937 or toll free (877) 564-1315. Additional information
location. If a nonprofi t organization or nonprofi t corporation, identify
and forms may be obtained from the Department’s Web site at
each offi cer and the individual designated as manager.
www. revenue.ne.gov/gaming.
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