Form 50G Schedule III "County/City Lottery Worker Application" - Nebraska

What Is Form 50G Schedule III?

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 III 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 III "County/City Lottery Worker Application" - Nebraska

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Form 50G
Nebraska Schedule III — County/City Lottery Worker Application
Schedule III
Incomplete applications 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 Worker Information
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 worker’s license are met.
3
4 Date of Birth
5 Type of Application
Social Security Number
c
c
c
c
c
New
Inactive
Report Changes
Renewal
Cancel
Name (Last name, first name, middle name)
DOR Use Only
Aliases, Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise
DOB Check
Street or Other Mailing Address
Y
N
City
State
Zip Code
County
Date
6 Provide a brief description of your duties as a county/city lottery worker by checking the boxes that apply to you.
Required to be Fingerprinted (see 6a and 6b)
c
Keno Manager
c
c
c
Accounting
Authorized Representative
Sales Outlet Officer or Owner
c
Individual other than keno manager who has
c
c
c
Administration
Governing Official
Security
authority over verification of winning number
c
c
c
Lottery Operator Officer or Owner
Audit
Other (specify)
selection by a manual or automated ball draw device.
6a 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?
c
c
Yes
No
Type of License:
If Yes, indicate the approximate date you were fingerprinted and the type of license involved.
Date:
6b Have you ever been fingerprinted by the Nebraska Liquor Control Commission in conjunction with an application for a liquor license?
c
c
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 6a and 6b, see the instructions on the reverse side of this application.
You must answer questions 7 through 9 accurately.
7 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.)
c
c
Yes
No
If you answered Yes, see the instructions on the reverse side of this application.
8 Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any other felony within ten years preceding the date of this application?
c
c
Yes
No
If you answered Yes, see the instructions on the reverse side of this application.
9 For New Applicants Only. For the purpose of complying with
Neb. Rev. Stat. §§ 4-108 through
4-114, I attest as follows:
c
I am a citizen of the United States; or
c
I am a qualified alien under the federal Immigration and Nationality Act, my immigration status and alien number are as follows:
,
and I agree to provide a copy of my USCIS documentation upon request.
Lottery Operator Information (Required unless working at a county, city, or village location.)
10 Nebraska ID Number
Name, Address, City, State, Zip Code
Lottery Sales Outlet Location Information (Required if working at a sales outlet location.)
11 Nebraska ID Number
Name, Address, City, State, Zip Code
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 hereby
attest that my response and the information provided in Line 9 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 the provisions of the Nebraska
sign
County and City Lottery Act and the regulations adopted under this Act.
here
Date
Daytime Phone Number
Signature of Applicant
Authorization – Signature of Governing Official or Authorized Representative
I declare that I have examined this application and authorize the applicant to submit it to the Nebraska Department of Revenue for approval.
sign
here
Signature of Governing Official or Authorized Representative
Title
Date
Daytime Phone Number
Printed Name of Official or Representative
Email Address
Retain a copy for your records.
12-2014
9-133-1993 Rev.
Supersedes 9-133-1993 Rev. 12-2009
Form 50G
Nebraska Schedule III — County/City Lottery Worker Application
Schedule III
Incomplete applications 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 Worker Information
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 worker’s license are met.
3
4 Date of Birth
5 Type of Application
Social Security Number
c
c
c
c
c
New
Inactive
Report Changes
Renewal
Cancel
Name (Last name, first name, middle name)
DOR Use Only
Aliases, Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise
DOB Check
Street or Other Mailing Address
Y
N
City
State
Zip Code
County
Date
6 Provide a brief description of your duties as a county/city lottery worker by checking the boxes that apply to you.
Required to be Fingerprinted (see 6a and 6b)
c
Keno Manager
c
c
c
Accounting
Authorized Representative
Sales Outlet Officer or Owner
c
Individual other than keno manager who has
c
c
c
Administration
Governing Official
Security
authority over verification of winning number
c
c
c
Lottery Operator Officer or Owner
Audit
Other (specify)
selection by a manual or automated ball draw device.
6a 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?
c
c
Yes
No
Type of License:
If Yes, indicate the approximate date you were fingerprinted and the type of license involved.
Date:
6b Have you ever been fingerprinted by the Nebraska Liquor Control Commission in conjunction with an application for a liquor license?
c
c
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 6a and 6b, see the instructions on the reverse side of this application.
You must answer questions 7 through 9 accurately.
7 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.)
c
c
Yes
No
If you answered Yes, see the instructions on the reverse side of this application.
8 Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any other felony within ten years preceding the date of this application?
c
c
Yes
No
If you answered Yes, see the instructions on the reverse side of this application.
9 For New Applicants Only. For the purpose of complying with
Neb. Rev. Stat. §§ 4-108 through
4-114, I attest as follows:
c
I am a citizen of the United States; or
c
I am a qualified alien under the federal Immigration and Nationality Act, my immigration status and alien number are as follows:
,
and I agree to provide a copy of my USCIS documentation upon request.
Lottery Operator Information (Required unless working at a county, city, or village location.)
10 Nebraska ID Number
Name, Address, City, State, Zip Code
Lottery Sales Outlet Location Information (Required if working at a sales outlet location.)
11 Nebraska ID Number
Name, Address, City, State, Zip Code
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 hereby
attest that my response and the information provided in Line 9 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 the provisions of the Nebraska
sign
County and City Lottery Act and the regulations adopted under this Act.
here
Date
Daytime Phone Number
Signature of Applicant
Authorization – Signature of Governing Official or Authorized Representative
I declare that I have examined this application and authorize the applicant to submit it to the Nebraska Department of Revenue for approval.
sign
here
Signature of Governing Official or Authorized Representative
Title
Date
Daytime Phone Number
Printed Name of Official or Representative
Email Address
Retain a copy for your records.
12-2014
9-133-1993 Rev.
Supersedes 9-133-1993 Rev. 12-2009
Instructions
Who Must File. Any individual who intends to perform any work directly related to the conduct of a county/city lottery,
except for individuals whose sole responsibilities are that of a keno writer, must complete and file this application. A
county/city lottery worker license applicant must be at least 19 years of age. Work directly related to the conduct of a
lottery means any work involving the actual day-to-day conduct of the lottery, including, but not limited to, winning
number selection, record keeping, shift checkout, review of keno writer banks, security, and compiling or filing county/
city lottery tax return information. Please refer to the County and City Lottery
Reg-35-619
for a detailed description
of individuals who are required to file this application.
When and Where to File. A properly completed and signed application must be on file with the Nebraska
Department of Revenue (Department) prior to a lottery worker beginning his or her duties. The application will
be considered on file with the Department once the Nebraska Schedule III is received by the Department, or as of the
date postmarked or electronically transmitted to the Department, provided the application is received by the Department
within 10 days after the date postmarked or electronically transmitted. An application not received within 10 days of
the date postmarked or electronically transmitted is not considered on file. The applicant must cease performing any
duties for the lottery until the Nebraska Schedule III is on file with the Department. A separate Nebraska Schedule III
must be submitted for each county, city, or village for which an individual will be performing duties related to the
conduct of the lottery. Incomplete applications will be returned to the county, city, or village and the lottery worker
license applicant must immediately cease working for the lottery until a properly completed application is on file
with the Department. In order to determine whether a license application is on file with the Department, contact the
Charitable Gaming Division by phone.
All lottery worker licenses expire on May 31 of every odd-numbered year, and may be renewed biennially. An application
for license renewal must be submitted to the Department at least 60 days prior to the expiration date of the license.
The Nebraska Schedule III may also be used to report changes in the application information, or to report that the license
is inactive or void. If a lottery worker is no longer working with a county/city lottery, the Department must be notified
by marking “inactive” on a Schedule III, and filing the form with the Department. Any changes in the information
originally submitted on the application form must be promptly reported to the Department. These changes are also to
be reported to the county, city, or village.
Each applicant should review the questions on the application carefully and provide accurate responses. If any of the
information provided by the applicant is found to be false, the applicant will be automatically disqualified. Disqualified
workers cannot work for a county/city lottery at any time. If the responses of a licensed lottery worker reporting changes
are found to be false, notice of license suspension, cancellation, or revocation may be issued.
There are three methods that can be used to file the Nebraska Schedule III. (1) Mail the Nebraska Schedule III and any
attachments to the Nebraska Department of Revenue, Charitable Gaming Division, PO Box 94855, Lincoln, NE 68509-
4855. (2) Fax the Nebraska Schedule III and any attachments electronically to 402-471-5600 and mail the original.
(3) Personally deliver the Nebraska Schedule III to any of the Department’s offices in Lincoln, Norfolk, North Platte,
Omaha, or Scottsbluff. Original signatures are required in order to process the application. Retain a copy of the Nebraska
Schedule III for your records and provide a copy to the county, city, or village listed at the top of the form.
Specific Instructions
Line 1. Nebraska ID Number. Enter the state ID number assigned to the county, city, or village. This number is
found on every county/city lottery license issued by the Department and is identified as 35-xxxxxxx. If this number is
unknown or not assigned, this space may be left blank.
Line 2. County, City, or Village Name. Enter the name of the county, city, or village for whom the applicant will be
working. This information is found on the license displayed at the location of the lottery or on the
Nebraska Application
for County/City Lottery, Form
50G. List only the county, city, or village on the license. If the lottery is conducted jointly
with another county, city, or village, file one Schedule III and indicate the name of each county, city, or village involved.
Line 5. A new application is required for each new lottery worker and anyone who has terminated employment
or is currently inactive, but wishes to resume work at a later date. If reporting changes to a previously-filed license
application, check the “report changes” box. Check the “inactive” box when an individual is no longer actively working
with a county/city lottery. The “cancel” box is to be marked only by a lottery worker to request cancellation of his or
her license. The “cancel” box may not be used by a county, city, village, or lottery operator to report that an
individual is no longer working for the county, city, village, or lottery operator.
Lines 6, 6a, and 6b. Fingerprinting Requirements. If a box in the left-hand column is marked and the applicant
answered “No” to lines 6a and 6b, the applicant must comply with the Instructions for Completing Fingerprint Application.
The applicant must also submit a Background Check Waiver form and the fingerprinting processing fee to the Department.
Lines 7 and 8. 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.
Line 9. For purposes of complying with
Neb. Rev. Stat. §§ 4-108 through
4-114, all new lottery worker license applicants
are required to complete this section. This information will be used by the Department to verify the license applicant’s
lawful presence in the United States. A license application will be denied if the information provided is false.
Line 10. Enter the state ID number and name of the lottery operator.
Line 11. Enter the state ID number and name of each lottery sales outlet location only if the applicant performs work
at the sales outlet location’s place of business. If a state ID number has not yet been assigned, this space may be left
blank. Enter only one sales outlet location per line. If additional space is needed, attach a separate sheet listing the
additional locations.
Authorized Signatures. The application must be signed by the applicant and by a governing official or their designated,
authorized representative to be valid.
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 at revenue.nebraska.gov/gaming.
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