Form MGCB-LC-3271 "Institutional Investor Manager Form" - Michigan

What Is Form MGCB-LC-3271?

This is a legal form that was released by the Michigan Gaming Control Board - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2011;
  • The latest edition provided by the Michigan Gaming Control Board;
  • 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 MGCB-LC-3271 by clicking the link below or browse more documents and templates provided by the Michigan Gaming Control Board.

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Download Form MGCB-LC-3271 "Institutional Investor Manager Form" - Michigan

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Michigan Gaming Control Board
3062 W. Grand Blvd, Suite L-700, Detroit, MI 48202-6062
Institutional Investor Manager Form
______
______
Name of Fund Manager
_____
_____
Date
REPORT SUSPICIOUS OR ILLEGAL GAMBLING RELATED ACTIVITY ANONYMOUSLY
ANONYMOUS TIP LINE PHONE NUMBER:
SUBMIT AN ANONYMOUS TIP AT:
1-888-314-2682
WWW.MICHIGAN.GOV/MGCB
MGCB-LC-3271 (Rev. 03/11)
1
Michigan Gaming Control Board
3062 W. Grand Blvd, Suite L-700, Detroit, MI 48202-6062
Institutional Investor Manager Form
______
______
Name of Fund Manager
_____
_____
Date
REPORT SUSPICIOUS OR ILLEGAL GAMBLING RELATED ACTIVITY ANONYMOUSLY
ANONYMOUS TIP LINE PHONE NUMBER:
SUBMIT AN ANONYMOUS TIP AT:
1-888-314-2682
WWW.MICHIGAN.GOV/MGCB
MGCB-LC-3271 (Rev. 03/11)
1
Institutional Investor Manager Form
This application form is authorized under the Michigan Gaming Control and Revenue Act (“Act”), 1997 PA 69, MCL
432.201 et. seq.
This form is to be used by the Fund Manager that manages a fund/investment for an Institutional Investor.
DEFINITIONS
The term ”fund manager” refers to the individual(s) responsible for managing the institutional investor and/or fund.
The term “Institutional Investor” in this form means any retirement fund administered by a public agency for the exclusive
benefit of federal, state, or local public employees, an employee benefit plan, or pension fund that is subject to the
employee retirement income security act of 1974, as amended, an investment company registered under the investment
company act of 1940, title I of chapter 686, 54 Stat. 789, 15 U.S.C. 80a-1 to 80a-3 and 80a-4 to 80a-64, a collective
investment trust organized by a bank under part 9 of the rules of the comptroller of the currency, a closed end investment
trust, a chartered or licensed life insurance company or property and casualty insurance company, a chartered or
licensed financial institution, an investment advisor registered under the investment advisers act of 1940, title II of chapter
686, 54 Stat. 847, 15 U.S.C. 80b-1 to 80b-21, or any other person as the board may determine for reasons consistent
with the Act.
The term ”security” in this form means any equity or debt instrument representing a source of funds provided to a casino
licensee or applicant or an affiliated company that has any relationship to the financing of the casino.
INSTRUCTIONS
The Fund Manager for an Institutional Investor must provide the Board with full and complete information, documents,
materials and certifications as requested in the application form, to the best of the Applicant’s knowledge and at the
Applicant’s sole expense.
The Board will not process or otherwise consider whether to grant the requested institutional investor waiver until Fund
Manager has completed the information, documents, materials and certifications provided. Any misrepresentation or
omission is grounds for application denial or other disciplinary action authorized under the Board’s
administrative rules.
MGCB-LC-3271 (Rev. 03/11)
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Institutional Investor Manager Form
Institutional Investor Manager
This form is to be completed by the “fund manager”… Referring to the individual
responsible for managing the institutional investor and/or fund.
Fund Manager Information
Fund Name:
Fund Manager’s Personal Information
Last Name:
First Name:
Full Middle Name:
Date of Birth:
Gender:
Male
Female
Social Security Number:
Driver License Number:
Issuing State:
Present Residential Address
Street Address:
City:
State:
Zip Code:
Country:
Contact Information
Telephone Number:
Extension:
Facsimile Number:
Email Address:
MGCB-LC-3271 (Rev. 03/11)
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Institutional Investor Manager Form
VOLUNTARY CONSENT TO RELEASE INFORMATION
To be filled out by the Institutional Investor Manager (Fund Manager).
I,
(NAME OF FUND MANAGER TO EXECUTE THIS RELEASE)
Authorize the Michigan Gaming Control Board, its employees and agents to conduct a preliminary background
check.
Therefore, I authorize and request that you release any and all information, materials and documents in your
possession which have been requested by any employee or agent of the Michigan Gaming Control Board
regarding my personal or business activities. I am voluntarily giving this consent to release information, materials
and documents provided that the employee or agent of the Michigan Gaming Control Board properly identifies
himself or herself as an agent or employee of the Michigan Gaming Control Board.
This authorization supersedes and countermands any prior authorization and request to the contrary.
This authorization supercedes and countermands any prior authorization and request to the contrary.
A photostatic copy of this authorization will be considered as effective and valid as the original.
IN WITNESS WHEREOF, I have executed this release at the city of ___________________, State of
__________________, on this ____ day of ___________, _____ .
________________________________________
Individual’s Signature
Before me, the undersigned, a Notary Public in and for said County and State, the above individual
personally appeared and acknowledged the execution of the foregoing instrument as his/her voluntary act and
deed.
WITNESS, my hand and Notary Seal, this ____ day of ___________, _____ .
__________________________________________
Notary Public, (Written Signature)
__________________________________________
Notary Public, (Printed Signature)
My commission expires:
County of residence:
MGCB-LC-3271 (Rev. 03/11)
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