Form 50G Schedule II "County/City Lottery Sales Outlet Location Application" - Nebraska

What Is Form 50G Schedule II?

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 II 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 II "County/City Lottery Sales Outlet Location Application" - Nebraska

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Nebraska Schedule II – County/City Lottery Sales Outlet Location Application
Form 50G
• No license fee required.
Schedule II
• Incomplete schedules will be returned.
1 Nebraska ID Number of County, City, or Village
Please Do Not Write In This Space
RESET FORM
PRINT FORM
2
County, City, or Village Name on Form 50G
Sales Outlet Location 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
City
State
Zip Code
Street Address
City
State
Zip Code
County
Nebraska Liquor License Number
6 Type of Ownership
7
Location Type
c
c
c
c
c
Sole Proprietorship
Domestic Corporation
Limited Liability Company
Nonprofit Corporation or Organization
Keno Satellite
c
c
c
c
c
Partnership
Foreign Corporation
Domesticated Corporation
Other _________________________
Keno Independent Game
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 sales outlet location’s license are met.
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 person 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.
e. If a nonprofit organization or nonprofit corporation, list each officer and the individual designated as manager.
(Attach additional sheet if necessary)
Type of Involvement and
Date of Birth
Social Security Number
Name, Address, City, State, Zip Code (See instructions)
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)
12 Do any of the individuals listed in line 8 above have a financial interest, directly or
10a Has anyone listed in line 8 ever been convicted of, forfeited bond upon a charge of, or
indirectly, in any company licensed as a manufacturer or distributor pursuant to the
pled guilty or nolo contendere to any felony or misdemeanor at any time involving any
Nebraska Bingo Act
or the
Nebraska Pickle Card Lottery Act
or in any company
gambling activity, fraud, theft, willful failure to make required payments or reports, or
licensed as a manufacturer-distributor pursuant to the
Nebraska County and City
filing false reports with a governmental agency at any level? This includes shoplifting or
Lottery
Act?
issuing bad checks.
c
c
Yes
No If Yes, see instructions.
c
c
Yes
No If Yes, attach a detailed explanation of such interests.
10b Has anyone listed in line 8 ever been convicted of, forfeited bond upon a charge of, or
pled guilty or nolo contendere to any felony other than that described in line 10a within
13 Does any member of the governing board or any governing official of the
10 years preceding the date of this application?
county, city, or village named in this application have any financial interest,
c
c
Yes
No If Yes, see instructions.
directly or indirectly, in the business named in this application?
11 Has each of the individuals listed in line 8 above complied with the
Instructions for
Completing Fingerprint
Application, or when applicable, filed a signed
Affidavit by
Spouse for Wavier
form?
c
c
Yes
No (See What Must Be Filed instructions)
14 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 of the
Nebraska County and City Lottery Act
and the regulations adopted under such Act.
sign
here
Signature of Sales Outlet Location Owner, Member, Partner,
Daytime Phone Number
Title
Date
Officer, 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
Attach documentation indicating approval of location by governing board of the county, city, or village and a copy of the site agreement.
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.
sign
here
Date
Authorized Signature
Title
Daytime Phone Number
Retain a copy for your records.
12-2014
9-132-1993 Rev.
Supersedes 9-132-1993 Rev. 6-2007
Nebraska Schedule II – County/City Lottery Sales Outlet Location Application
Form 50G
• No license fee required.
Schedule II
• Incomplete schedules will be returned.
1 Nebraska ID Number of County, City, or Village
Please Do Not Write In This Space
RESET FORM
PRINT FORM
2
County, City, or Village Name on Form 50G
Sales Outlet Location 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
City
State
Zip Code
Street Address
City
State
Zip Code
County
Nebraska Liquor License Number
6 Type of Ownership
7
Location Type
c
c
c
c
c
Sole Proprietorship
Domestic Corporation
Limited Liability Company
Nonprofit Corporation or Organization
Keno Satellite
c
c
c
c
c
Partnership
Foreign Corporation
Domesticated Corporation
Other _________________________
Keno Independent Game
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 sales outlet location’s license are met.
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 person 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.
e. If a nonprofit organization or nonprofit corporation, list each officer and the individual designated as manager.
(Attach additional sheet if necessary)
Type of Involvement and
Date of Birth
Social Security Number
Name, Address, City, State, Zip Code (See instructions)
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)
12 Do any of the individuals listed in line 8 above have a financial interest, directly or
10a Has anyone listed in line 8 ever been convicted of, forfeited bond upon a charge of, or
indirectly, in any company licensed as a manufacturer or distributor pursuant to the
pled guilty or nolo contendere to any felony or misdemeanor at any time involving any
Nebraska Bingo Act
or the
Nebraska Pickle Card Lottery Act
or in any company
gambling activity, fraud, theft, willful failure to make required payments or reports, or
licensed as a manufacturer-distributor pursuant to the
Nebraska County and City
filing false reports with a governmental agency at any level? This includes shoplifting or
Lottery
Act?
issuing bad checks.
c
c
Yes
No If Yes, see instructions.
c
c
Yes
No If Yes, attach a detailed explanation of such interests.
10b Has anyone listed in line 8 ever been convicted of, forfeited bond upon a charge of, or
pled guilty or nolo contendere to any felony other than that described in line 10a within
13 Does any member of the governing board or any governing official of the
10 years preceding the date of this application?
county, city, or village named in this application have any financial interest,
c
c
Yes
No If Yes, see instructions.
directly or indirectly, in the business named in this application?
11 Has each of the individuals listed in line 8 above complied with the
Instructions for
Completing Fingerprint
Application, or when applicable, filed a signed
Affidavit by
Spouse for Wavier
form?
c
c
Yes
No (See What Must Be Filed instructions)
14 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 of the
Nebraska County and City Lottery Act
and the regulations adopted under such Act.
sign
here
Signature of Sales Outlet Location Owner, Member, Partner,
Daytime Phone Number
Title
Date
Officer, 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
Attach documentation indicating approval of location by governing board of the county, city, or village and a copy of the site agreement.
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.
sign
here
Date
Authorized Signature
Title
Daytime Phone Number
Retain a copy for your records.
12-2014
9-132-1993 Rev.
Supersedes 9-132-1993 Rev. 6-2007
Instructions
Who Must File. Any individual, business, nonprofit organization, or nonprofit corporation that has contracted with a
lottery operator to conduct a lottery on behalf of a county, city, or village must apply for and obtain a lottery sales outlet
location license. This includes any individual or business whose only involvement with the operation of the lottery is
providing space to the lottery operator, even if the space is leased to and staffed by the lottery operator.
What Must Be Filed. Any individual, business, nonprofit organization or nonprofit corporation seeking a license as
a lottery sales outlet location must complete and submit a Nebraska Schedule II - County/City Lottery Sales Outlet
Location Application, Form 50G, to the Nebraska Department of Revenue (Department).
When and Where to File. A license issued to a lottery sales outlet location 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, and the
Nebraska Schedule I - County/City Lottery Operator Application, Form
50G, or submitted
separately if the county, city, or village and lottery operator are already licensed. Applications for license renewal must
be submitted to the Department at least 60 days prior to the expiration date of the license. No license application fee
is required.
The Nebraska Schedule II 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.
Mail the original application form and any attachments 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.
Specific Instructions
Line 6. Type of Ownership. Enter the type of ownership under which the applicant 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 is 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 has domesticated in Nebraska.
Line 7. A keno satellite location is separate from a main keno location and electronically linked to the main location,
but does not conduct its own winning number selection. An independent keno game location is not electronically linked
to another location and does conduct its own winning number selection.
Line 8. Identify 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 of each person who has any interest in the entity
to be licensed as a lottery sales outlet location. If a nonprofit organization or nonprofit corporation, identify each officer
and the individual designated as manager.
A person is a debt holder of the corporation, partnership, or limited liability company if such person holds any
mortgages, notes, bonds, convertible debentures, or other obligations, whether written or oral, issued by the corporation,
partnership, or limited liability company. For purposes of this application, 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. A person is an equity holder of the corporation, partnership, or limited liability company if such person
holds any capital stock, whether common or preferred, or any ownership interest or share issued by the corporation,
partnership, or limited liability company.
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 10a and 10b. If the “Yes” box is checked, provide an attachment with the following information, if known:
1.
The date and place the incident occurred;
2.
The court case or docket number under which it is filed;
3.
The original charge and ultimate disposition of the matter; and
4.
A description of the events which are the subject of the incident.
Neb. Rev. Stat., § 9-1,104
requires all new applicants for a lottery sales outlet location license to be fingerprinted
Line 11.
for criminal background investigation purposes. Please refer to the
Instructions for Completing Fingerprint Application
to determine who is subject to this requirement. Fingerprinting of a spouse will be waived if an
Affidavit by Spouse
for Waiver of Fingerprinting
and/or
Personal History Record and Background Disclosure Form
for Charitable Gaming
Licensees accompanies the application form. Fingerprinting may be waived for those applicants who have previously
filed fingerprint cards with the Nebraska Liquor Control Commission.
Authorized Signatures. The application must be signed by a lottery sales outlet location owner, member, partner,
officer, or person 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 county/city/village approval of the applicant to participate in
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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