Form 50g - Nebraska Application For County/city Lottery
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1
2Nebraska Application for County/City Lottery
form
• Include license fee of $100
• Incomplete applications will be returned
50G
• Read instructions on reverse side
Please do NoT WrITe IN THIs sPace
RESET FORM
1 Do you hold or have you previously held a
2 Federal Employer I.D. or Social Security
Number
Nebraska Identification Number?
YES
NO
3 County Location in Nebraska
If yes, give number
Name aNd locaTIoN address
Name aNd maIlING address
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
4 Type of License
5 Type of Application
6 Date of Election
7 Have any ordinances or resolutions been
adopted which relate to the lottery activity?
County / City Lottery — $100 Fee
New
YES
NO
Lottery Operator — $500 Fee
Renewal
(Attach Nebraska Schedule I)
If new application, attach certified
Report Changes
If Yes, attach copies of the approved
Sales Outlet Location - No Fee
copy of election results.
ordinances or resolutions.
Cancel
(Attach Nebraska Schedule II)
8 Type of Lottery
9 Location of Records
10 Method of Winning Number Selection
Manual Ball Draw
Ticket Drawing
Keno
Same as Location Address
Same as Mailing Address
Automated Ball Draw
Other, enter address
Submit samples of tickets, prize payout
Random Number Generator
information, lottery rules and any other
Both Manual or Automated Ball Draw
written documentation describing the
and Random Number Generator
lottery activity.
Address
City
State
Zip Code
(Attach a schedule showing when each will be used)
11 Primary County, City, or Village Representative
Name, Address, City, State, Zip Code
Daytime Telephone Number
12 Authorized Representative(s) (for purposes of approving and signing lottery worker license applications)
Daytime Telephone Number
Name, Address, City, State, Zip Code
13 Identify Separate Bank Account and Financial Institution of County, City, or Village
Account Number
Name, Address, City, State, Zip Code
14 Have you contracted with a lottery operator to conduct the lottery on your behalf?
NO
YES
If Yes, attach Nebraska Schedule I and a copy of the executed lottery operator agreement.
15 Lottery Location(s) (Attach additional sheet if necessary. Attach a Nebraska Schedule II and copy of the site agreement for each location.)
Name, Address, City, State, Zip Code
16 Will your lottery be conducted jointly with another county, city, or village pursuant to the Interlocal Cooperation Act?
YES
NO
If Yes, indicate the county, city, or village involved and attach a copy of the proposed agreement.
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
Signature of Governing Official
Title
Date
Daytime Telephone Number
Mail this application and fees to:
NeBraska deParTmeNT of reVeNue, cHarITaBle GamING dIVIsIoN, P.o. BoX 94855, lINcolN, Ne 68509-4855
3-2009
9-065-1989 Rev.
Please make a coPy for your records.
Supersedes 9-065-1989 Rev. 3-2003
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