Form 50G "Nebraska Application for County/City Lottery" - Nebraska

What Is Form 50G?

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 March 1, 2009;
  • 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 50G by clicking the link below or browse more documents and templates provided by the Nebraska Department of Revenue.

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Download Form 50G "Nebraska Application for County/City Lottery" - Nebraska

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Nebraska Application for County/City Lottery
form
• Include license fee of $100
50G
• Incomplete applications will be returned
• 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)
Name, Address, City, State, Zip Code
Daytime Telephone Number
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
Nebraska Application for County/City Lottery
form
• Include license fee of $100
50G
• Incomplete applications will be returned
• 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)
Name, Address, City, State, Zip Code
Daytime Telephone Number
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
INsTrucTIoNs
WHo musT fIle. Any county, city or village which has approved a
regulations for play and collection of prizes and progressive game
lottery by an election must apply for and obtain a county/city lottery
prizes; oversight of the lottery operation; and all record keeping.
license prior to conducting such lottery.
lINe 10. Indicate the method of winning number selection to be used
in a keno lottery activity. If both a manual ball draw or automated
WHeN aNd WHere To fIle. All licenses issued to any county,
ball draw and a random number generator are used, attach a separate
city or village to conduct a lottery expire on May 31 of every
schedule showing the days and times each will be used. The method
even-numbered year and may be renewed on a biennial basis. All
initially used may only be changed once during the business day. For
applications for license renewal must be submitted to the Nebraska
example, if you begin the day using a random number generator, you
Department of Revenue at least 60 days prior to the expiration of
can change to a manual ball draw at the predesignated time, but no
the license. A county, city or village which has not been previously
further changes are allowed for that business day.
licensed may submit the application at any time during the period
covered by the license. License fees are due in full for the biennial
lINe 11. Indicate the name, address and daytime telephone number
licensing period. However, if a new license application is received
of one individual who represents the county, city, or village in all
by the Department and the license will become effective on or after
matters relating to the conduct of the lottery activity. This individual
June 1 of the second year of the biennial licensing period, the license
would be the primary contact person for the Department.
fee to be remitted to the Department is one-half of the biennial fee.
lINe 12. Indicate the name, address and daytime telephone number
The application may also be utilized during the period covered by the
of the individual(s) who are authorized to sign and approve the lottery
license to report changes in the application information or to cancel
worker license applications for submission to the Department in lieu
the license. Any changes in the information originally submitted on
of a governing official.
the application must be reported to the Department within 30 days
lINe 13. Indicate the bank account number and the name and address
of the change(s).
of the financial institution where the net proceeds from the lottery
activity are deposited. The Nebraska County and City Lottery Act
Mail the application with the appropriate fees, schedules and
requires the gross proceeds of the lottery, less the amount awarded in
attachments to the Nebraska Department of Revenue, Charitable
prizes and any commission paid to a lottery operator plus any interest
Gaming Division, P.O. Box 94855, Lincoln, Nebraska 68509-4855.
on such funds, to be segregated from other revenue of the county,
Please make a copy of the application for your records. Checks written
city, or village and placed in a separate bank account.
to the Department of Revenue may be presently electronically.
lINe 14. If you have contracted with a lottery operator to conduct
sPecIfIc INsTrucTIoNs
the lottery on your behalf, attach Nebraska Schedule I – County/City
Name aNd locaTIoN address. Enter the name of the county,
Lottery Operator Application and a copy of the final ized agreement
city, or village applying for the license.
between the county, city or village and the lottery operator.
Name aNd maIlING address. Enter the mailing address to
lINe 15. Indicate the name and address of each location where
which all information concerning county/city lottery activities should
lottery tickets will be sold or keno will be played. If the location
be mailed. The Nebraska County/City Lottery Tax Return, Form 51C,
is other than the location of the lottery operator, attach Nebraska
which is used to report and pay the lottery tax on the gross proceeds
Schedule II – County/City Lottery Sales Outlet Location Application
will be mailed to this address.
and a copy of the site agreement for each such location. Also, each
location must be approved by the county, city, or village based upon
lINe 4. Enter the type of license application. A county, city or village
qualification standards that have been established by ordinance
which contracts with a lottery operator to conduct the lottery on its
or resolution. The qualification standards must be filed with the
behalf must include the Nebraska Schedule I – County/City Lottery
Department within 30 days of their adoption. A county, city, or village
Operator Application with a new or renewal application. If the selected
must notify the Department of all approved lottery locations within
lottery operator conducts the lottery at a location other than its own,
30 days of their approval.
Nebraska Schedule II – County/City Lottery Sales Outlet Location
lINe 16. The Nebraska County and City Lottery Act allows the
Application must be included for each such location.
conduct of the lottery only within the geographic boundaries of the
defINITIoN. Lottery operator is any individual, sole proprietorship,
county, city, or village which has approved the lottery activ ity unless an
limited liability company, partnership, or corporation which operates
agreement pursuant to the Interlocal Cooperation Act has been made
a lottery on behalf of a county, city, or village. A lottery operator is
with another county, city, or village to conduct a joint lottery. Each
selected by the county, city, or village to conduct the lottery in its
county, city, or village which is a party to the agreement must have
entirety on behalf of the county, city, or village. A written contract
approved the lottery activity by election and must apply separately for
is executed which sets forth the obligations and responsibilities for
its own lottery license. A copy of the agreement must be attached to
both parties. A lottery operator typically has overall responsibility
this application and is subject to approval by the Department.
for the daily operation of the lottery including, but not limited
sIGNaTure. The application must be signed by a member of the
to, responsibility and liability for all operational aspects of the
governing board or a governing official of the county, city, or village.
lottery which includes daily gaming operations; purchase, repair,
replacement, and maintenance of lottery equipment; purchase and
Any questions regarding the completion of this application should
maintenance of lottery supplies; compensation, staffing, and training
be addressed to the Nebraska Department of Revenue, Chari table
of all employees and agents; processing and handling lottery gross
Gaming Division, P.O. Box 94855, Lincoln, Nebraska 68509-4855,
proceeds; preparation of all reports required of a county, city, or
telephone (402) 471-5937 or toll free (877) 564-1315. Additional
village, or lottery operator by the Department or any governmental
information and forms may be obtained from the Department’s Web
entity or agency; advertising; development of official rules and
site at revenue.nebraska.gov/gaming.
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