Form 50h - Nebraska Application For Utilization Of Funds Member

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Nebraska Application for Utilization of Funds Member

FORM

• Include license fee of $40.

50H

• Incomplete applications will be returned.

1 Licensed Organization’s Name

PLEASE DO NOT WRITE IN THIS SPACE

RESET FORM

2 Nebraska ID Number of Licensed

3 Type of Application

Organization

Report Changes

New

Renewal

Cancel (Return License)

Utilization of Funds Member Information (Attach additional sheet, if necessary.)

Social Security Number

Name

Street Address

Date of Birth

PO Box

City

State

Zip Code

County

Your social security number and date of birth are required under the Nebraska Bingo Act, Nebraska Pickle Card Lottery Act, and

the Nebraska Lottery and Raffle Act and will be used to request criminal history information from law enforcement agencies

to determine if the legal requirements for a utilization of funds member’s license are met.

4 Are you an active and bona fide member of the licensed organization named above?

YES

If Yes, indicate the date (month/day/year) you became a member:

5 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a manufacturer or distributor of bingo equipment and/or pickle

card units in Nebraska?

If Yes, provide detailed explanation:

YES

6 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a commercial lessor of bingo premises in Nebraska?

YES

If Yes, provide detailed explanation:

7 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a pickle card operator in Nebraska?

If Yes, provide detailed explanation:

YES

8 Do you hold or have you 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?

If Yes, indicate the types of licenses and check current status:

YES

Active

Suspended

Cancelled

Revoked

Expired

9a Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any FELONY OR MISDEMEANOR AT ANY TIME

involving fraud, theft, any gambling activity, willful failure to make required payments or reports, or filing false reports with a government agency at any

level? This INCLUDES shoplifting or issuing bad checks.

YES

9b Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony other than those listed in 9a within the last

ten years?

YES

If you answered Yes to 9a or 9b, indicate the date and place the incident occurred, the court case or docket number under which it is filed, the original

charge or ultimate disposition of the matter, and a description of the events which are the subject of the incident.

10 For New Applicants Only. For the purpose of complying with Neb. Rev. Stat. §§ 4-108 through 4-114, I attest as follows:

I am a citizen of the United States; or

I am a qualified alien under the federal Immigration and Nationality Act. My immigration status and alien number are as

follows:__________________________________, and I agree to provide a copy of my USCIS documentation upon request.

Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete. I hereby attest

that my response and the information provided in Line 10 and any related application for public benefits are true, complete, and accurate. I understand that this

information may be used to verify my lawful presence in the United States. I will comply with all of the provisions of the Nebraska Bingo Act, the Nebraska Pickle

Card Lottery Act, the Nebraska Lottery and Raffle Act, the Nebraska Small Lottery and Raffle Act, and the regulations adopted under such Acts.

sign

here

Signature of Applicant

Date

Daytime Telephone Number

E-Mail Address

LICENSED ORGANIZATION AUTHORIZATION—Signature of Officer

I declare that I have examined this application and approve the person to act as a utilization of funds member on behalf of the above-named licensed organization.

sign

here

Signature of Officer (Other than Applicant)

Date

Daytime Telephone Number

Mail the original application and $40 fee to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, PO BOX 94855, LINCOLN, NE 68509-4855

9-188-2001 Rev. 11-2010 Supersedes 9-188-2001 Rev. 5-2008