Form 50f - Nebraska Registration And Report Of Pickle Card Dispensing Devices
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6Nebraska registration and report
ForM
of Pickle card Dispensing Devices
50F
• Include $50 fee per device
• read instructions on reverse side
Please Do Not Write iN this sPace
RESET FORM
Nebraska Identification Number
Federal Employer Identification or Social Security Number
County of Business Location in Nebraska
NaMe aND locatioN aDDress
NaMe aND MailiNG aDDress
Name
Name
Trade Name of Business (If different than above)
Street or Other Mailing Address
Street Address
City
State
Zip Code
City
State
Zip Code
FOR DEPT. OF REVENUE USE ONLY
Type of Pickle Card License Held
Type of Application
Replacement
Operator
Class I
Class II
New
Renewal
Transfer
Penalty
$50 Fee required for each Device registered
• If any of the devices being registered are rented or leased/purchased, a copy of the rental/lease agreement must be provided.
• For each pickle card dispensing device to be added or renewed, complete the following:
• Attach schedule for additional pickle card dispensing devices to be added or renewed.
Manufacturer (See instructions)
Make/Model
Serial Number
Decal Number Issued
Description
Stamp Machine
Multiple Column Dispensing Device
Other
Ownership
If Rented or Leased, Name of Lessor
Nebraska Identification Number of Lessor
Rent
Owned
Rented
lease Period
Beginning Date _____________________Ending Date _____________________ .
$
per
Leased/Purchased
(Attach a copy of your lease agreement unless previously filed with the Department.)
Manufacturer (See instructions)
Make/Model
Serial Number
Decal Number Issued
Description
Stamp Machine
Multiple Column Dispensing Device
Other
Ownership
If Rented or Leased, Name of Lessor
Nebraska Identification Number of Lessor
Rent
Owned
Rented
lease Period
Beginning Date _____________________Ending Date _____________________ .
$
per
(Attach a copy of your lease agreement unless previously filed with the Department.)
Leased/Purchased
Manufacturer (See instructions)
Make/Model
Serial Number
Decal Number Issued
Description
Stamp Machine
Multiple Column Dispensing Device
Other
Ownership
If Rented or Leased, Name of Lessor
Nebraska Identification Number of Lessor
Rent
Owned
Rented
lease Period
Beginning Date _____________________Ending Date _____________________ .
$
per
Leased/Purchased
(Attach a copy of your lease agreement unless previously filed with the Department.)
1 Number of pickle card dispensing devices to be registered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Registration fee (line 1 multiplied by $50) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 $
3 Number of pickle card dispensing devices not properly registered (For Dept . of Revenue Use Only) 3
4 Penalty (line 3 multiplied by $30) (For Dept . of Revenue Use Only) . . . . . . . . . . . . . . . . . . . . . . . . . . 4 $
5 Total amount due (line 2 plus line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 $
Under penalties of law, I declare that I have examined this report, and to the best of my knowledge and belief,
sign
it is correct and complete .
here
Authorized Signature (See instructions)
Title
Date
Daytime Telephone Number
FOR DEPARTMENT OF REVENUE USE ONLY
sign
here
Signature of Department of Revenue Representative
Title
Date
Mail the original application and the total amount due to:
NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, P.O. BOX 94855, LINCOLN, NE 68509-4855
Nebraska Pickle Card Dispensing Device Information Guide, October 28, 2009, Page 1
Please make a copy for your records .
Page 1
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