Form 50C "Nebraska Application for Gaming Manager" - Nebraska

What Is Form 50C?

This is a legal form that was released by the Nebraska Department of Revenue - a government authority operating within Nebraska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2013;
  • The latest edition provided by the Nebraska Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 50C by clicking the link below or browse more documents and templates provided by the Nebraska Department of Revenue.

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Download Form 50C "Nebraska Application for Gaming Manager" - Nebraska

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Nebraska Application for Gaming Manager
Form
50C
•  License fee is $100.
•  Incomplete applications will be returned.
1 Licensed Organization’s Name
Please Do Not Write in This Space
2 Nebraska ID Number of Licensed Organization
3 Type of Application
PRINT FORM
RESET FORM
New
Report Changes
Renewal
Cancel (Return license)
Gaming Manager 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, and will be used to request criminal history
information from law enforcement agencies to determine if the legal requirements for a gaming manager’s license are met.
4 Are you currently a bingo chairperson or alternate bingo chairperson, as indicated on the Nebraska Schedule I – Bingo License, Form 50, submitted by any licensed organization?
Yes
No
If Yes, indicate the licensed organization’s name and Nebraska ID Number:
Licensed Organization’s Name
Nebraska ID Number
5 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?
Yes
No
If Yes, indicate the types of licenses and their current status (active, suspended, canceled, revoked, expired):
6 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a commercial lessor of bingo premises or as a manufacturer or distributor of bingo
equipment and/or pickle card units in Nebraska?
Yes
No
If Yes, provide a detailed explanation:
7a 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 governmental agency at any level? This includes shoplifting or issuing bad checks.
Yes
No
7b 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 7a within the last 10 years?
Yes
No
If you answered Yes to 7a or 7b, 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.
8 Have you ever been fingerprinted for a license under the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, or the Nebraska County and City Lottery Act?
Yes
No
Type of License:
If Yes, indicate the approximate date you were fingerprinted and the type of license involved.
Date:
9 Have you ever been fingerprinted by the Nebraska Liquor Control Commission in conjunction with an application for a liquor license?
Yes
No
Liquor License Number:
If Yes, indicate the approximate date you were fingerprinted and the number of the liquor license. Date:
If you answered No to lines 8 and 9, see the instructions for lines 8 and 9 on the reverse side of this application.
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__________________________________, and I
agree to provide a copy of my USCIS documentation upon request.
11 Type of Compensation
$
Salary
per
Other, explain
Volunteer, no compensation
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 Phone Number
Email Address
Licensed Organization Authorization — Signature of Utilization of Funds Member
I declare that I have examined this application and approve the person to act as a gaming manager on behalf of the above-named licensed organization.
sign
(
)
here
Daytime Phone Number
Signature of Utilization of Funds Member
Date
Mail this application, attachments, forms, and all applicable fees to:
Nebraska Department of Revenue, Charitable Gaming Division, PO Box 94855, Lincoln, NE 68509-4855.
revenue.nebraska.gov/gaming, 877-564-1314 or 402-471-5937
9-186-2001 Rev. 12-2013 Supersedes 9-186-2001 Rev. 11-2010
Nebraska Application for Gaming Manager
Form
50C
•  License fee is $100.
•  Incomplete applications will be returned.
1 Licensed Organization’s Name
Please Do Not Write in This Space
2 Nebraska ID Number of Licensed Organization
3 Type of Application
PRINT FORM
RESET FORM
New
Report Changes
Renewal
Cancel (Return license)
Gaming Manager 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, and will be used to request criminal history
information from law enforcement agencies to determine if the legal requirements for a gaming manager’s license are met.
4 Are you currently a bingo chairperson or alternate bingo chairperson, as indicated on the Nebraska Schedule I – Bingo License, Form 50, submitted by any licensed organization?
Yes
No
If Yes, indicate the licensed organization’s name and Nebraska ID Number:
Licensed Organization’s Name
Nebraska ID Number
5 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?
Yes
No
If Yes, indicate the types of licenses and their current status (active, suspended, canceled, revoked, expired):
6 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a commercial lessor of bingo premises or as a manufacturer or distributor of bingo
equipment and/or pickle card units in Nebraska?
Yes
No
If Yes, provide a detailed explanation:
7a 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 governmental agency at any level? This includes shoplifting or issuing bad checks.
Yes
No
7b 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 7a within the last 10 years?
Yes
No
If you answered Yes to 7a or 7b, 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.
8 Have you ever been fingerprinted for a license under the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, or the Nebraska County and City Lottery Act?
Yes
No
Type of License:
If Yes, indicate the approximate date you were fingerprinted and the type of license involved.
Date:
9 Have you ever been fingerprinted by the Nebraska Liquor Control Commission in conjunction with an application for a liquor license?
Yes
No
Liquor License Number:
If Yes, indicate the approximate date you were fingerprinted and the number of the liquor license. Date:
If you answered No to lines 8 and 9, see the instructions for lines 8 and 9 on the reverse side of this application.
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__________________________________, and I
agree to provide a copy of my USCIS documentation upon request.
11 Type of Compensation
$
Salary
per
Other, explain
Volunteer, no compensation
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 Phone Number
Email Address
Licensed Organization Authorization — Signature of Utilization of Funds Member
I declare that I have examined this application and approve the person to act as a gaming manager on behalf of the above-named licensed organization.
sign
(
)
here
Daytime Phone Number
Signature of Utilization of Funds Member
Date
Mail this application, attachments, forms, and all applicable fees to:
Nebraska Department of Revenue, Charitable Gaming Division, PO Box 94855, Lincoln, NE 68509-4855.
revenue.nebraska.gov/gaming, 877-564-1314 or 402-471-5937
9-186-2001 Rev. 12-2013 Supersedes 9-186-2001 Rev. 11-2010
Instructions
Who Must File. Any nonprofit organization, volunteer fire company, or volunteer first-aid, rescue, ambulance, or emergency
squad applying for a Class II license to conduct bingo must license an individual as a gaming manager. The gaming manager is
responsible for the supervision and operation of the bingo game on behalf of the licensed organization and the conduct of all other
gaming activities permitted by law at a bingo game, including lottery by the sale of pickle cards, lotteries, and raffles.
What Must be Filed. The Nebraska Application for Gaming Manager, Form 50C, must be filed by any individual wishing to
function as a gaming manager for a licensed organization. An individual may be licensed as a gaming manager for more than one
licensed organization. A separate Form 50C and $100 license fee must be submitted for each licensed organization.
An individual licensed as a gaming manager may not be connected with, interested in, or otherwise concerned directly or indirectly
with any party licensed as a manufacturer or distributor of bingo equipment or pickle cards or as a commercial lessor of bingo
premises. An individual licensed as a gaming manager may not be a bingo chairperson, or alternate bingo chairperson nor hold
any other type of license issued under the
Nebraska Bingo
Act, the
Nebraska Lottery and Raffle
Act, and the
Nebraska Pickle Card
Lottery
Act.
When and Where to File. A gaming manager license issued to an individual for a licensed organization holding a certificate
of exemption under Internal Revenue Code (IRC) § 501(c)(3) or (c)(4) expires on September 30 of each odd-numbered year and
may be renewed biennially. A gaming manager license issued to an individual for a licensed organization holding a certificate
of exemption under IRC § 501(c)(5), (c)(8), (c)(10), or (c)(19) or any volunteer fire company or volunteer first-aid, rescue,
ambulance, or emergency squad expires on September 30 of each even-numbered year and may be renewed biennially. All
applications for license renewal must be submitted with the licensed organization’s bingo license renewal application at least
45 days prior to the expiration date of the license. An individual who has not been previously licensed as a gaming manager may
submit the application at any time during the licensing period. License fees are due in full for the biennial licensing period. However,
if a new license application is received by the Nebraska Department of Revenue (Department) and the license will become effective
on or after October 1 of the second year of the biennial licensing period, the license fee to be remitted to the Department is one-half
of the biennial fee. Checks written to the Nebraska Department of Revenue may be presented electronically.
The application may also be used during the licensing period to report changes in the application information originally submitted or to
cancel the license. If requesting cancellation of the license, please include the original license certificate issued by the Department.
Mail the original application and required license fee, Background Check Waiver form, and fingerprint processing fee to the
Nebraska Department of Revenue, Charitable Gaming Division, PO Box 94855, Lincoln, NE 68509-4855. Retain a copy of this
application for your records.
An individual must have physical possession of the license issued by the Department before he or she may work at a bingo occasion
as a gaming manager.
Specific Instructions
Line 4. Each organization licensed to conduct bingo must designate a member of its organization as a bingo chairperson. A
licensed organization may also designate up to three alternate bingo chairpersons. If a licensed organization has designated you as
its bingo chairperson or alternate bingo chairperson, provide that organization’s name and Nebraska ID number. That organization
must replace you as a bingo chairperson or alternate bingo chairperson before you can be issued a gaming manager’s license. No
person designated as a bingo chairperson or alternate bingo chairperson may hold a license as a gaming manager.
Line 5. Identify any licenses you currently hold or have previously held which were 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. Include the
status of these licenses (active, suspended, cancelled, revoked, or expired).
Line 6. Provide a complete explanation of any interest which you or your spouse may have in any business licensed as a
commercial lessor of bingo premises or as a manufacturer or distributor of bingo equipment and/or pickle card units in Nebraska.
For purposes of line 6, interest would include, but not be limited to, ownership of any type which you or your spouse have in a sole
proprietorship, limited liability company, partnership, or corporation licensed as a distributor, manufacturer, or commercial lessor.
Neb. Rev. Stat. § 9-1,104
requires certain applicants to be fingerprinted for criminal background investigation purposes.
Lines 8 and 9.
If you answered “No” to lines 8 and 9, please refer to the
Instructions for Completing Fingerprint Application
as you are subject to this
requirement. You must also submit a
Background Check Waiver
form and the fingerprint processing fee to the Department.
Line 10. For purposes of complying with
Neb. Rev. Stat. §§ 4-108
through 4-114, all new gaming manager applicants are required
to complete this section. This information will be used by the Department to verify the applicant’s lawful presence in the United
States. A license application will be denied if the information provided is false.
Licensed Organization Authorization . The application for the gaming manager’s license must be signed by a utilization
of funds member of the licensed organization for which you will function as a gaming manager. The signature of the utilization
of funds member is necessary to establish that the licensed organization approves you to function as a gaming manager at its
bingo occasions.
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