Form CGCC-CH2-11 "Supplemental Information Schedules" - California

What Is Form CGCC-CH2-11?

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

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the California Gambling Control Commission;
  • 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 CGCC-CH2-11 by clicking the link below or browse more documents and templates provided by the California Gambling Control Commission.

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Download Form CGCC-CH2-11 "Supplemental Information Schedules" - California

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State of California
California Gambling Control Commission
Supplemental Information:
Schedules
CGCC-CH2-11 (New 05/20)
Page 1 of 12
MAIL COMPLETED FORM TO:
BUREAU OF GAMBLING CONTROL
P.O. Box 168024
Sacramento, CA 95816-8024
(916) 830-1700
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU COMPLETE THIS FORM
This form is used to provide additional information for applicants required to be licensed by the California Gambling Control
Commission (Commission).
All responses must be truthful and complete. All responses and supplemental documentation are subject to verification and will be
used to determine suitability under the Gambling Control Act and Commission regulations. Any misrepresentation or failure to
disclose required information or documentation may constitute cause for denial of the application or discipline of the licensee.
All information must be typed or printed legibly in blue or black ink. Any questions that do not apply should be indicated with “N/A”
(Not Applicable). If the space available is insufficient, attach a separate sheet of paper and precede each answer with the applicable
section and question number. Any corrections, changes, or other alterations must be initialed and dated by the applicant.
TYPE OF APPLICANT (CHECK APPROPRIATE BOX):
TPPPS O
T
L
TPPPS S
L
WNER
YPE
ICENSEE
UPERVISOR
ICENSEE
C
O
T
L
K
E
L
ARDROOM
WNER
YPE
ICENSEE
EY
MPLOYEE
ICENSEE
State of California
California Gambling Control Commission
Supplemental Information:
Schedules
CGCC-CH2-11 (New 05/20)
Page 1 of 12
MAIL COMPLETED FORM TO:
BUREAU OF GAMBLING CONTROL
P.O. Box 168024
Sacramento, CA 95816-8024
(916) 830-1700
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU COMPLETE THIS FORM
This form is used to provide additional information for applicants required to be licensed by the California Gambling Control
Commission (Commission).
All responses must be truthful and complete. All responses and supplemental documentation are subject to verification and will be
used to determine suitability under the Gambling Control Act and Commission regulations. Any misrepresentation or failure to
disclose required information or documentation may constitute cause for denial of the application or discipline of the licensee.
All information must be typed or printed legibly in blue or black ink. Any questions that do not apply should be indicated with “N/A”
(Not Applicable). If the space available is insufficient, attach a separate sheet of paper and precede each answer with the applicable
section and question number. Any corrections, changes, or other alterations must be initialed and dated by the applicant.
TYPE OF APPLICANT (CHECK APPROPRIATE BOX):
TPPPS O
T
L
TPPPS S
L
WNER
YPE
ICENSEE
UPERVISOR
ICENSEE
C
O
T
L
K
E
L
ARDROOM
WNER
YPE
ICENSEE
EY
MPLOYEE
ICENSEE
Supplemental Information: Schedules
Page 2 of 12
SCHEDULE A – ASSETS
Cash
List all cash and identify its location (e.g., financial institutions [foreign and domestic], safe deposit boxes, house/office, etc.).
N
A
AME AND
DDRESS OF
N
(
)
P
(
)
AME
S
OF
ERSON
S
WITH
E
/L
L
6 D
D
B
NTITY
OCATION
AST
IGITS OF
ATE
ALANCE
T
A
D
O
S
A
Y
E
B
*
C
B
YPE OF
CCOUNT
ATE
PENED
IGNATURE
UTHORITY ON
EAR
ND
ALANCE
URRENT
ALANCE
W
F
A
N
W
R
HERE THE
UNDS ARE
CCOUNT
UMBER
AS
ECORDED
A
CCOUNT
H
ELD
T
OTAL
*Balance as of the most recent calendar year: December 31, 20____.
Signature of Preparer: ___________________________________
Date: _________________________
I declare under penalty of perjury under the laws of the State of California that the information contained in this form is true, accurate, and complete, and that this declaration is
executed by me at
.
City and State
APPLICANT’S PRINTED NAME
SIGNATURE
CAPACITY
DATE (MM/DD/YYYY)
Supplemental Information: Schedules
Page 3 of 12
SCHEDULE B – ASSETS
Stocks and Bonds
List stocks, bonds, mutual funds, or other similar investments held or controlled
L
6 D
N
Y
E
D
M
AST
IGITS OF
UMBER OF
EAR
ND
ATE
ARKET
T
(N
S
, B
,
C
YPE
OTE IF
TOCK
OND
URRENT
I
R
O
A
S
M
V
W
SSUER
EGISTERED
WNER
CCOUNT
HARES OR
ARKET
ALUE
AS
M
F
,
.)
M
V
UTUAL
UND
ETC
ARKET
ALUE
N
U
V
*
R
UMBER
NITS
ALUE
ECORDED
T
OTAL
*Market value as of the most recent calendar year: December 31, 20____.
Signature of Preparer: ___________________________________
Date: _________________________
I declare under penalty of perjury under the laws of the State of California that the information contained in this form is true, accurate, and complete, and that this declaration is
executed by me at
.
City and State
APPLICANT’S PRINTED NAME
SIGNATURE
CAPACITY
DATE (MM/DD/YYYY)
Supplemental Information: Schedules
Page 4 of 12
SCHEDULE C – ASSETS
Accounts and Notes Receivable
List all loans, accounts, and notes receivable (monies owed). Please submit copies of agreements for any loans/accounts/notes receivable.
D
ATE
M
P
P
(
.
.,
ATURITY
AYMENT
ERIOD
E
G
D
P
I
O
Y
E
B
ATE
AYMENT
NTEREST
RIGINAL
EAR
ND
ALANCE
N
D
D
(
,
,
B
AME OF
EBTOR
ATE
NOTES
WEEKLY
MONTHLY
ALANCE
A
A
R
A
B
*
W
CQUIRED
MOUNT
ATE
MOUNT
ALANCE
AS
R
)
.)
ECEIVABLE
ETC
R
ECORDED
T
OTAL
*Balance as of the most recent calendar year: December 31, 20____.
Signature of Preparer: ___________________________________
Date: _________________________
I declare under penalty of perjury under the laws of the State of California that the information contained in this form is true, accurate, and complete, and that this declaration is
executed by me at
.
City and State
APPLICANT’S PRINTED NAME
SIGNATURE
CAPACITY
DATE (MM/DD/YYYY)
Supplemental Information: Schedules
Page 5 of 12
SCHEDULE D – ASSETS
Business Investments
List any business investments in which any direct, indirect, or vested interest is held, along with the names of all individuals or entities that have a direct, indirect, or vested
interest. This should include, but not be limited to, sole proprietorships, joint ventures, partnerships, limited liability companies, and corporations.
D
ATE
N
Y
E
C
UMBER
EAR
ND
URRENT
T
N
W
P
D
I
T
P
A
YPE OF
AME IN
HICH
ERCENTAGE
ATE OF
NITIAL
OTAL
URCHASE
MOUNT
E
N
S
M
I
NTITY
AME
OF
HARES
ARKET
NVESTMENT
E
H
O
P
/I
P
/I
W
NTITY
ELD
OF
WNERSHIP
URCHASE
NVESTMENT
RICE
NVESTMENT
AS
U
V
*
A
OR
NITS
ALUE
MOUNT
R
ECORDED
IDENTIFY THE SOURCE OF MONIES FOR THE INITIAL AND SUBSEQUENT INVESTMENTS (INCLUDE DATES AND SPECIFIC AMOUNTS OF SUBSEQUENT INVESTMENTS). IN LOANS, PROVIDE COPIES OF AGREEMENTS.
IF SAVINGS, IDENTIFY SOURCE (E.G. BUSINESS REVENUE, ETC.)
IDENTIFY THE SOURCE OF MONIES FOR THE INITIAL AND SUBSEQUENT INVESTMENTS (INCLUDE DATES AND SPECIFIC AMOUNTS OF SUBSEQUENT INVESTMENTS). IN LOANS, PROVIDE COPIES OF AGREEMENTS.
IF SAVINGS, IDENTIFY SOURCE (E.G. BUSINESS REVENUE, ETC.)
IDENTIFY THE SOURCE OF MONIES FOR THE INITIAL AND SUBSEQUENT INVESTMENTS (INCLUDE DATES AND SPECIFIC AMOUNTS OF SUBSEQUENT INVESTMENTS). IN LOANS, PROVIDE COPIES OF AGREEMENTS.
IF SAVINGS, IDENTIFY SOURCE (E.G. BUSINESS REVENUE, ETC.)
T
OTAL
*Market value as of the most recent calendar year: December 31, 20____.
Signature of Preparer: ___________________________________
Date: _________________________
I declare under penalty of perjury under the laws of the State of California that the information contained in this form is true, accurate, and complete, and that this declaration is
executed by me at
.
City and State
APPLICANT’S PRINTED NAME
SIGNATURE
CAPACITY
DATE (MM/DD/YYYY)
Page of 12