Form 50G Schedule I "County/City Lottery Operator Application" - Nebraska

What Is Form 50G Schedule I?

This is a legal form that was released by the Nebraska Department of Revenue - a government authority operating within Nebraska.The document is a supplement to Form 50G, Nebraska Application for County/City Lottery. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2014;
  • 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 Schedule I 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 Schedule I "County/City Lottery Operator Application" - Nebraska

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Nebraska Schedule I – County/City Lottery Operator Application
Form 50G
• Include license fee of $500.
Schedule I
• Incomplete schedules will be returned.
Please Do Not Write In This Space
1 Nebraska ID Number of County, City, or Village
PRINT FORM
RESET FORM
2
County, City, or Village Name on Form 50G
Lottery Operator Information (Attach additional sheet if necessary)
3 Nebraska ID Number
4 Federal ID or Social Security Number
5 Type of Application:
c
c
c
c
New
Renewal
Report Changes
Cancel
Business Name and Location Address
Business Name and Mailing Address
Name
Business Name
Trade Name of Business (If Different Than Above)
Street or Other Mailing Address
Street Address
City
State
Zip Code
City
State
Zip Code
County
6 Type of Ownership
7
If the applicant is a corporation, limited liability company,
or partnership, under the laws of what state has it been
c
c
c
c
Sole Proprietorship
Domestic Corporation
Limited Liability Company
Other ______________
incorporated, formed, or organized?
c
c
c
Partnership
Foreign Corporation
Domesticated Corporation
• Your Social Security number and date of birth are required under the Nebraska County and City Lottery Act and will be used to request criminal history information
from law enforcement agencies to determine if the legal requirements for a lottery operator’s license are met.
• Each applicant for a license as a lottery operator is subject to a background investigation and/or an inspection of its facilities. The Department may require the
applicant to pay the actual costs incurred in conducting such investigation or inspection.
8 List the Social Security number, full name, home address, date of birth, type of involvement, and percentage of ownership for each of the following persons involved with the applicant.
a. If a sole proprietorship, list the individual owner.
b. If a partnership, list each partner and spouse.
c. If a corporation, list each officer and spouse and each person holding 10% or more of the debt or equity of the applicant corporation. If any entity holding 10% or more of the
debt or equity of the applicant corporation is a partnership, limited liability company, or corporation, list each partner of such partnership, each member of such limited liability
company, or each officer of such corporation and every person holding 10% or more of the debt or equity of any such partnership, limited liability company or corporation.
d. If a limited liability company, list each member and spouse.
(Attach additional sheet if necessary)
Type of Involvement and
Name, Address, City, State, Zip Code (See instructions)
Date of Birth
Social Security Number
Percentage of Ownership
9 Does any person other than those listed in line 8 above have any ownership interest in the license applicant? (See instructions)
c
c
Yes
No
If Yes, in the case of an individual, identify the Social Security number, full name, home address, date of birth, type of ownership interest of each such individual. In the case of a
business, identify the federal employer ID number, business name, address, and type of ownership interest of each such business. (Attach additional sheet if necessary)
10 Has each of the individuals listed in line 8 above complied with the
Instructions for
11a List those individuals, if any, from line 8 above who have previously filed
Completing Fingerprint
Application, or when applicable, filed a signed
Affidavit by
fingerprint cards with the Nebraska Liquor Control Commission.
Spouse for Waiver
Form?
c
c
No (See What Must Be Filed instructions)
Yes
12 Has each of the individuals listed in line 8 above completed and filed a
Personal History
Record and Background Disclosure
Form, or when applicable, attached a signed
Affidavit by Spouse for Waiver
Form?
1 1b Nebraska Liquor License Number
c
c
Yes
No (See What Must Be Filed instructions)
14 Does any member of the governing board or any governing official of the
13 Do any of the individuals listed in line 8 above have a financial interest, directly or
indirectly, in any company licensed as a manufacturer or distributor pursuant to the
county, city, or village named in this application have any financial interest,
directly or indirectly, in the business named in this application?
Nebraska Bingo Act
or the
Nebraska Pickle Card Lottery Act
or in any company
licensed as a manufacturer-distributor pursuant to the
Nebraska County and City
c
c
Yes
No
Lottery
Act?
c
c
If Yes, attach a detailed explanation of such interests.
Yes
No If Yes, attach a detailed explanation of such interests.
15 Do any of the individuals listed in line 8 above currently hold or have they 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?
c
c
Yes
No If Yes, indicate the types of licenses, and their current status (active, suspended, cancelled, revoked, or expired).
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
sign
of the Nebraska County and City Lottery Act and the regulations adopted under such Act.
here
Signature of Lottery Operator Owner, Member, Partner, Officer,
Title
Date
Daytime Phone Number
or Person Authorized by Attached Power of Attorney
Name of Person to Contact Regarding This Application:
Name
Title
Daytime Phone Number
Authorization – Signature of Governing Official
sign
I declare that I have examined this application, and authorize the applicant to conduct a lottery on behalf of the county, city, or village named in this application.
here
Date
Authorized Signature
Title
Daytime Phone Number
Retain a copy for your records.
12-2014
9-066-1989 Rev.
Supersedes 9-066-1989 Rev. 6-2008
Nebraska Schedule I – County/City Lottery Operator Application
Form 50G
• Include license fee of $500.
Schedule I
• Incomplete schedules will be returned.
Please Do Not Write In This Space
1 Nebraska ID Number of County, City, or Village
PRINT FORM
RESET FORM
2
County, City, or Village Name on Form 50G
Lottery Operator Information (Attach additional sheet if necessary)
3 Nebraska ID Number
4 Federal ID or Social Security Number
5 Type of Application:
c
c
c
c
New
Renewal
Report Changes
Cancel
Business Name and Location Address
Business Name and Mailing Address
Name
Business Name
Trade Name of Business (If Different Than Above)
Street or Other Mailing Address
Street Address
City
State
Zip Code
City
State
Zip Code
County
6 Type of Ownership
7
If the applicant is a corporation, limited liability company,
or partnership, under the laws of what state has it been
c
c
c
c
Sole Proprietorship
Domestic Corporation
Limited Liability Company
Other ______________
incorporated, formed, or organized?
c
c
c
Partnership
Foreign Corporation
Domesticated Corporation
• Your Social Security number and date of birth are required under the Nebraska County and City Lottery Act and will be used to request criminal history information
from law enforcement agencies to determine if the legal requirements for a lottery operator’s license are met.
• Each applicant for a license as a lottery operator is subject to a background investigation and/or an inspection of its facilities. The Department may require the
applicant to pay the actual costs incurred in conducting such investigation or inspection.
8 List the Social Security number, full name, home address, date of birth, type of involvement, and percentage of ownership for each of the following persons involved with the applicant.
a. If a sole proprietorship, list the individual owner.
b. If a partnership, list each partner and spouse.
c. If a corporation, list each officer and spouse and each person holding 10% or more of the debt or equity of the applicant corporation. If any entity holding 10% or more of the
debt or equity of the applicant corporation is a partnership, limited liability company, or corporation, list each partner of such partnership, each member of such limited liability
company, or each officer of such corporation and every person holding 10% or more of the debt or equity of any such partnership, limited liability company or corporation.
d. If a limited liability company, list each member and spouse.
(Attach additional sheet if necessary)
Type of Involvement and
Name, Address, City, State, Zip Code (See instructions)
Date of Birth
Social Security Number
Percentage of Ownership
9 Does any person other than those listed in line 8 above have any ownership interest in the license applicant? (See instructions)
c
c
Yes
No
If Yes, in the case of an individual, identify the Social Security number, full name, home address, date of birth, type of ownership interest of each such individual. In the case of a
business, identify the federal employer ID number, business name, address, and type of ownership interest of each such business. (Attach additional sheet if necessary)
10 Has each of the individuals listed in line 8 above complied with the
Instructions for
11a List those individuals, if any, from line 8 above who have previously filed
Completing Fingerprint
Application, or when applicable, filed a signed
Affidavit by
fingerprint cards with the Nebraska Liquor Control Commission.
Spouse for Waiver
Form?
c
c
No (See What Must Be Filed instructions)
Yes
12 Has each of the individuals listed in line 8 above completed and filed a
Personal History
Record and Background Disclosure
Form, or when applicable, attached a signed
Affidavit by Spouse for Waiver
Form?
1 1b Nebraska Liquor License Number
c
c
Yes
No (See What Must Be Filed instructions)
14 Does any member of the governing board or any governing official of the
13 Do any of the individuals listed in line 8 above have a financial interest, directly or
indirectly, in any company licensed as a manufacturer or distributor pursuant to the
county, city, or village named in this application have any financial interest,
directly or indirectly, in the business named in this application?
Nebraska Bingo Act
or the
Nebraska Pickle Card Lottery Act
or in any company
licensed as a manufacturer-distributor pursuant to the
Nebraska County and City
c
c
Yes
No
Lottery
Act?
c
c
If Yes, attach a detailed explanation of such interests.
Yes
No If Yes, attach a detailed explanation of such interests.
15 Do any of the individuals listed in line 8 above currently hold or have they 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?
c
c
Yes
No If Yes, indicate the types of licenses, and their current status (active, suspended, cancelled, revoked, or expired).
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
sign
of the Nebraska County and City Lottery Act and the regulations adopted under such Act.
here
Signature of Lottery Operator Owner, Member, Partner, Officer,
Title
Date
Daytime Phone Number
or Person Authorized by Attached Power of Attorney
Name of Person to Contact Regarding This Application:
Name
Title
Daytime Phone Number
Authorization – Signature of Governing Official
sign
I declare that I have examined this application, and authorize the applicant to conduct a lottery on behalf of the county, city, or village named in this application.
here
Date
Authorized Signature
Title
Daytime Phone Number
Retain a copy for your records.
12-2014
9-066-1989 Rev.
Supersedes 9-066-1989 Rev. 6-2008
Instructions
Who Must File. Any individual or business that has contracted with a county, city, or village to conduct a lottery on its behalf
must apply for and obtain a lottery operator license. A separate license is required for each county, city, or village on whose behalf
a lottery will be conducted by the lottery operator.
What Must Be Filed. Any individual or business seeking a license as a lottery operator must complete and submit a Nebraska
Schedule I - County/City Lottery Operator Application, Form 50G, to the Nebraska Department of Revenue (Department).
When and Where to File. A license issued to a lottery operator expires on May 31 of every even-numbered year and may be
renewed biennially. The application may be submitted with the
Nebraska Application for County/City Lottery, Form
50G, or
submitted separately if the county, city, or village is already licensed. Applications for license renewal must be submitted to the
Department at least 60 days prior to the expiration date of the license.
License fees are due in full for the biennial licensing period. However, if a new license application is received by the Department
and the license will become effective on or after June 1 of the second year of the biennial licensing period, the license fee will be
one-half of the biennial fee.
Mail the original application form 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. Checks written to the Department may be presented electronically.
The Nebraska Schedule I may also be used to report changes in the application information or to cancel the license. Any change in
the information originally submitted on the application must be provided to the Department within 30 days of the change.
An individual or business must have physical possession of the license issued by the Department before they can operate as a
lottery operator.
Specific Instructions
Line 6. Type of Ownership. Enter the type of ownership under which the applicant business is operated. A partnership includes
all types of partnerships, including general, limited, and joint ventures. A domestic corporation is a corporation which is organized
under the laws of Nebraska and has qualified to do business in this state. A foreign corporation is a corporation which is organized
under the laws of another state. A domesticated corporation is a foreign corporation that is domesticated in Nebraska.
Line 7. If your business is a corporation, limited liability company, or partnership, enter the name of the state under the laws of
which the business has been formed. The
Nebraska County and City Lottery Act
requires a lottery operator to be a resident of
Nebraska or, if a partnership, organized under the laws of Nebraska, or if a corporation, incorporated under the Nebraska Business
Corporation Act, or if a limited liability company, formed under the Limited Liability Company Act. A nonprofit organization or
nonprofit corporation is not eligible to obtain a lottery operator license.
Line 8. Provide the Social Security number, name, address, date of birth, type of involvement (owner, member, partner, officer,
debt or equity holder, or spouse), and percentage of ownership for each person who has any interest in the business to be licensed
as a lottery operator.
A person is a debt holder of a partnership, limited liability company, or corporation if they hold any mortgages, notes, bonds,
convertible debentures, or other obligations, whether written or oral, issued by the partnership, limited liability company, or
corporation. A person is an equity holder of the partnership, limited liability company, or corporation if they hold any capital stock,
whether common or preferred, or any ownership interest or share issued by the partnership, limited liability company, or corporation.
A debt holder does not include any financial institution organized or chartered under the laws of Nebraska, any other state, or the
United States relating to banks, savings institutions, trust companies, savings and loan associations, credit unions, installment loan
licensees, or similar associations organized under the laws of Nebraska and subject to supervision by the Department of Banking
and Finance.
Line 9. Identify any persons who have an ownership interest in the license applicant not listed in line 8. Owner means a person
with a right to share in the profits, losses, or liabilities of an applicant or licensee. The term includes loan guarantors who make
actual debt payments for or contribute capital to a license applicant or licensee with a contingent right to share in the profits, losses,
or liabilities of the operation. The term ownership interest is synonymous with owner.
Lines 10, 11a, 11b, and 12.
Neb. Rev. Stat. § 9-1,104
requires all applicants for a lottery operator license to be fingerprinted for
criminal background investigation purposes. Please refer to the
Instructions for Completing Fingerprint Application
to determine
who is subject to this requirement. Each individual listed must also submit a
Background Check Waiver
form and the fingerprint
processing fee to the Department.
Authorized Signatures. The application must be signed by an owner, member, partner, or officer of the applicant, or an individual
authorized by an attached
power of
attorney.
County/City Authorization. The application must also be signed by a member of the governing board or a governing official of
the county, city or village as an indication of approval of the applicant to conduct the lottery on its behalf.
Any questions regarding the completion of this application should be addressed to the Nebraska Department of Revenue, Charitable
Gaming Division, PO Box 94855, Lincoln, NE 68509-4855, 402-471-5937, or 877-564-1315. Additional information and forms
may be obtained from revenue.nebraska.gov/gaming.
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