Form 50H "Nebraska Application for Utilization of Funds Member" - Nebraska

What Is Form 50H?

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 November 1, 2010;
  • 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 50H by clicking the link below or browse more documents and templates provided by the Nebraska Department of Revenue.

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Download Form 50H "Nebraska Application for Utilization of Funds Member" - Nebraska

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Nebraska Application for Utilization of Funds Member
FORM
50H
• Include license fee of $40.
• Incomplete applications will be returned.
1 Licensed Organization’s Name
PLEASE DO NOT WRITE IN THIS SPACE
RESET FORM
2 Nebraska ID Number of Licensed
3 Type of Application
Organization
New
Report Changes
Cancel (Return License)
Renewal
Utilization of Funds Member 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, Nebraska Pickle Card Lottery Act, and
the Nebraska Lottery and Raffle Act and will be used to request criminal history information from law enforcement agencies
to determine if the legal requirements for a utilization of funds member’s license are met.
4 Are you an active and bona fide member of the licensed organization named above?
NO
YES
If Yes, indicate the date (month/day/year) you became a member:
5 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a manufacturer or distributor of bingo equipment and/or pickle
card units in Nebraska?
NO
YES
If Yes, provide detailed explanation:
6 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a commercial lessor of bingo premises in Nebraska?
NO
YES
If Yes, provide detailed explanation:
7 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a pickle card operator in Nebraska?
If Yes, provide detailed explanation:
NO
YES
8 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?
NO
YES
If Yes, indicate the types of licenses and check current status:
Active
Suspended
Cancelled
Revoked
Expired
9a 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 government agency at any
level? This INCLUDES shoplifting or issuing bad checks.
NO
YES
9b 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 9a within the last
ten years?
NO
YES
If you answered Yes to 9a or 9b, 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.
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 as
follows:__________________________________, and I agree to provide a copy of my USCIS documentation upon request.
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 Telephone Number
E-Mail Address
LICENSED ORGANIZATION AUTHORIZATION—Signature of Officer
sign
I declare that I have examined this application and approve the person to act as a utilization of funds member on behalf of the above-named licensed organization.
here
Signature of Officer (Other than Applicant)
Date
Daytime Telephone Number
Mail the original application and $40 fee to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, PO BOX 94855, LINCOLN, NE 68509-4855
9-188-2001 Rev. 11-2010 Supersedes 9-188-2001 Rev. 5-2008
Nebraska Application for Utilization of Funds Member
FORM
50H
• Include license fee of $40.
• Incomplete applications will be returned.
1 Licensed Organization’s Name
PLEASE DO NOT WRITE IN THIS SPACE
RESET FORM
2 Nebraska ID Number of Licensed
3 Type of Application
Organization
New
Report Changes
Cancel (Return License)
Renewal
Utilization of Funds Member 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, Nebraska Pickle Card Lottery Act, and
the Nebraska Lottery and Raffle Act and will be used to request criminal history information from law enforcement agencies
to determine if the legal requirements for a utilization of funds member’s license are met.
4 Are you an active and bona fide member of the licensed organization named above?
NO
YES
If Yes, indicate the date (month/day/year) you became a member:
5 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a manufacturer or distributor of bingo equipment and/or pickle
card units in Nebraska?
NO
YES
If Yes, provide detailed explanation:
6 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a commercial lessor of bingo premises in Nebraska?
NO
YES
If Yes, provide detailed explanation:
7 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a pickle card operator in Nebraska?
If Yes, provide detailed explanation:
NO
YES
8 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?
NO
YES
If Yes, indicate the types of licenses and check current status:
Active
Suspended
Cancelled
Revoked
Expired
9a 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 government agency at any
level? This INCLUDES shoplifting or issuing bad checks.
NO
YES
9b 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 9a within the last
ten years?
NO
YES
If you answered Yes to 9a or 9b, 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.
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 as
follows:__________________________________, and I agree to provide a copy of my USCIS documentation upon request.
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 Telephone Number
E-Mail Address
LICENSED ORGANIZATION AUTHORIZATION—Signature of Officer
sign
I declare that I have examined this application and approve the person to act as a utilization of funds member on behalf of the above-named licensed organization.
here
Signature of Officer (Other than Applicant)
Date
Daytime Telephone Number
Mail the original application and $40 fee to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, PO BOX 94855, LINCOLN, NE 68509-4855
9-188-2001 Rev. 11-2010 Supersedes 9-188-2001 Rev. 5-2008
INSTRUCTIONS
WHO MUST FILE. Any nonprofit organization, volunteer fire company, or volunteer first-aid, rescue, ambulance,
or emergency squad applying for a license to conduct bingo, a lottery by the sale of pickle cards, or a lottery or
raffle must license an individual as a utilization of funds member. The utilization of funds member is responsible
for ensuring that the gross receipts/proceeds from the gaming activity are properly accounted for and that they are
used only for those purposes permitted by law.
WHEN AND WHERE TO FILE. A utilization of funds member license issued to an individual for a nonprofit
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 utilization of funds member
license issued to an individual for a nonprofit organization holding a certificate of exemption under IRC § 501,
other than 501(c)(3) or (c)(4), or for 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 nonprofit organization’s 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 utilization of funds member 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 submit ted or to cancel the license. If requesting cancellation of the license, please include the original
license certificate issued by the Department.
The application and the required license fee are to be mailed to the Nebraska Department of Revenue, Charitable
Gaming Division, PO Box 94855, Lincoln, NE 68509-4855. Please make a copy of this application form for
your records.
An individual must have physical possession of the license issued by the Department before he or she may work as
a utilization of funds member for the licensed organization.
SPECIFIC INSTRUCTIONS
LINE 4. An applicant for a utilization of funds member license must have been an active and bona fide member of
the organization for at least one year prior to his or her application for a license, unless the one-year membership
requirement would impose an undue hardship on the organization. Indicate the month-day-year in which you became
a member of the organization. If you have not been a member for at least one year, you must attach documentation
showing that the one-year membership requirement would impose a hardship on the organization. The Department may
request additional information to prove membership or support the claim that the one-year membership requirement
imposes a hardship on the organization.
LINE 8. 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 an indication of the status of such licenses (active, suspended, canceled, revoked,
or expired). Attach additional sheets if necessary.
LINE 10. For purposes of complying with
Neb. Rev. Stat. §§ 4-108 through
4-114, all new utilization of funds
member 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.
Any questions regarding the completion of the Nebraska Applica tion for Utilization of Funds Member, Form 50H,
should be addressed to the Nebraska Department of Revenue, Charitable Gaming Division, PO Box 94855,
Lincoln, NE 68509-4855, phone 402-471-5937 or 877-564-1315, revenue.nebraska.gov/gaming.
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