Forms Retails by cuu74057


More Info
									                                      APPLICATION INSTRUCTIONS

Please read the following instructions carefully before completing the forms in this application package.

                                     SPECIAL NOTE: CHAIN STORES

Applications from chain outlets should be submitted through the chain central office, not by the individual
store. If your business is part of a chain, check with your central office before completing this form. If your
business is part of a chain that is applying for a retail license for the first time, the chain headquarters
must complete a separate application package.

                                       CONDITIONS OF LICENSING

Read the Conditions of Licensing thoroughly and sign. By signing it, you are agreeing to these conditions.

                                              LICENSING FEE

By law, applicants are required to pay a processing fee of $50 per location. The $50 covers required
record checks and other processing costs and is not refundable.

                                LOTTERY RETAILER RESPONSIBILITIES

Read the Lottery Retailer Responsibilities thoroughly and sign. By signing it, you are agreeing to these

                                         RETAILER APPLICATION

Complete the Retailer Application. Failure to complete all items may result in delay in processing or the
return of your application. The following line–by–line instructions may be helpful.

         1.      Insert the name of your business as it is most commonly known.

         2.      If the legal name of the business is different from its common name, insert the legal

         3.      Street address of the business.

         4.      City where business is located.

         5.      State where business is located.

         6.      Zip code of the business location.

         7.      The person(s) authorized to order lottery tickets.

         8.      Phone number of the business.

         9.      Hours your business is open Monday through Sunday.

         10.     For a sole proprietorship, list the sole owner. For a general partnership, list any partner.
                 For a limited partnership or corporation, please list the person responsible for financial
                 decisions and obligation for the above named business (duly authorized officer).

         11.     Phone number of the person listed above as “OWNER” or “PARTNER” or “DULY
                 AUTHORIZED OFFICER.”

         12.     If your mailing address is different from the street address of your business (P.O. Box,
                 etc.), please indicate here.

         13.     City of mailing address if different from the city where business is located.

Rev. 8/3/2010                                                                                             1 of 2
         14.     State of mailing address if different from the state where business is located.

         15.     Zip code of mailing address if different from the zip code where business is located.

         16.     County in which the business is located.

         17.     Indicate the business type that most closely describes your business. If “other,” please
                 describe fully.

         18.     Each question in the Business/Individual Information section must be marked “Yes” or
                 “No” or the application will be returned. If any question is answered “Yes,” please provide
                 complete details on a separate sheet.

         19.     Read the Certification language completely before you sign the application. The person
                 listed above as “OWNER” or “PARTNER” or “DULY AUTHORIZED OFFICER” must
                 sign the application.

         NOTE: Keep a copy of the Retailer Application for your records. Return the original copy to the
         Montana Lottery, as well as the other completed required forms and licensing fee.


         Fully complete this form and return it with the other required forms to the Montana Lottery,
         2525 North Montana Avenue, Helena, MT 59601.

                                             PERSONAL DATA FORM

         For a sole proprietorship, the owner must complete this form. For a general partnership,
         submit the requested information for each individual with 10% or more interest in the business.
         For a limited partnership or corporation, the president and vice president must complete the
         form. The form must be fully completed to expedite processing of your application.


         Arrange with your bank to authorize electronic funds transfer (EFT) and complete the enclosed
         form. If you are not familiar with EFT, some general information regarding the process is
         enclosed. If you have any difficulty with your bank, contact the Lottery.

         If your electronic funds transfer will come from a checking account, be sure to attach a voided
         check as indicated with the form. Only if your electronic funds transfer will come from a
         savings account, attach a deposit slip instead.

Rev. 8/3/2010                                                                                            2 of 2
                                     CONDITIONS OF LICENSING
By completing an application, the applicant agrees:

    1.     That a nonrefundable licensing fee of $50 (check or money order) will accompany the
           Retailer Application.

    2.     That a license is not assignable or transferable, and the licensee agrees to immediately
           notify the Montana Lottery of any change in business ownership or business locations.

    3.     That the business may not claim to be a Lottery Retailer unless a license is granted.

    4.     To prominently display the license in such a manner that the license is visible and in a
           manner so as to prevent theft or defacing of the license.

    5.     That all Lottery tickets activated for sale by the licensee (except for those returned In the
           times and manners prescribed by the Montana Lottery) are considered to have been
           purchased by the licensee and are the property of the licensee.

    6.     To make payments for all Lottery tickets by Electronic Funds Transfer (EFT) or in
           accordance with other directives of the Montana Lottery.

    7.     To maintain authorized displays, notices, and other materials used in conjunction with
           Lottery ticket sales in accordance with instructions issued by the Montana Lottery.

    8.     To redeem winning Lottery tickets as prescribed in directives of the Montana Lottery.

    9.     That Lottery tickets will be sold only on the premises of the business designated on the
           license. Persons selling and buying Lottery tickets must be 18 years of age or older.

    10. That Lottery tickets will not be sold at any price greater than the price stated on the

    11. To be bound by and comply with the rules, regulations, and directives of the Montana

    12. That the licensee and all employees of the licensee who will be involved in the sale,
        bookkeeping, or any other aspect of the Montana Lottery will read the Lottery law and
        rules of the Lottery Commission concerning retail licenses and be familiar with such laws
        and rules.

    Owner/Partner/Duly Authorized Officer (Circle One)

    Name (Please print) __________________________________________________________

    Signature___________________________Title_____________________ Date___________

Rev. 8/3/2010

                                  Lottery Retailer Responsibilities
                            Criteria for Placement and Retention of a Lottery Terminal

A retailer must first be licensed as a Lottery retailer by the Montana Lottery. This includes the retailer providing an
application to the Lottery along with a $50 application fee.
Once the application has been approved, the new Lottery retailer qualifies for placement of a lotto terminal.

Location, Space, and Electrical Requirements
The new retailer must sell both terminal–generated tickets and scratch tickets. Prior to receiving the lotto terminal, the
new Lottery retailer must provide prominent space for the terminal and scratch ticket dispenser(s) at an agreed–upon
location in the store. Neither the terminal nor the scratch ticket dispenser(s) may be moved without prior Lottery approval.
Following are the space requirements:
         Lotto terminal                    15" W x 17" D x 19" H
         Printer                           6 " W x 9" D x 6" H
         Scratch ticket dispenser(s)       Depends on scratch ticket strategy used
In addition the retailer must provide an electrical duplex–grounded outlet, operational 24 hours per day, and a 20-
amp circuit breaker.
The retailer must also have a telephone near enough to the terminal location that the terminal may be operated at
the same time the operator talks on the phone.

Sales Requirements
The retailer must sell all terminal–generated games and at least eight scratch games, although the Lottery
recommends a 16-game strategy.
The retailer must meet or exceed minimum sales requirements for a combination of terminal–generated and scratch
tickets. Failure to meet assigned sales minimum may result in removal of the terminal.

Ticket Redemption Requirements
The retailer must redeem winning terminal–generated and scratch tickets during all hours and days the store is open.
The retailer must pay each valid winning ticket claim of $599 or less.

Signage and Point–of–Sale Requirements
The retailer must prominently display, in an agreed–upon location, current point–of–sale materials, inside and
outside Lottery signage, and informational materials supplied by the Lottery.

Abiding by Statute, Rules, Procedures
The retailer must abide by all provisions of the Montana Lottery statute and all rules, procedures, and instructions
issued by the Lottery.
I have read the above and understand my responsibilities for receiving and retaining a lotto terminal.
Owner/Partner/Duly Authorized Officer (Circle One)

Signature                                           Date                         Title

Rev. 8/3/2010
                                          Retailer Application
Chain Name: (For Lottery Use Only)                               Chain Control #     (For Lottery Use Only)
Business Name:
Legal Name:
City:                                            State:                            Zip:
Contact:                                                         Phone: (      )
Business Hours:       From:                                      To:
Owner / Partner / Duly Authorized officer:
Phone: (      )                      Mailing Address:
City:                                            State:                            Zip:
Business Type (Check One)
Convenience Store               Drug Store                 Newsstand                  Service station
Grocery Store/market            Restaurant                 Bar/Lounge/Casino          Liquor Store

Does this business or the individuals listed on the Personal Data Form owe any taxes or
debts to the State of Montana?                                                                    YES         NO
Has this business or the listed individuals:
               *ever been sued, have outstanding claims or judgments?                             YES         NO
               *ever been convicted of a felony or gambling related offense?                      YES         NO
               *ever filed for bankruptcy in Montana or the US, been placed in
                receivership or made any assignments to creditors?                                YES         NO
               *ever held or applied for or presently hold a gambling, liquor, beer
                or lottery license in the State of Montana or elsewhere?                          YES         NO
               *ever operated under different names?                                              YES         NO

I hereby certify that the foregoing information is true and complete. I understand that false or misleading
statements are cause for denial of this application and/or suspension or revocation of the Lottery Retailer
License. I authorize the State of Montana to investigate my financial records, financial sources, criminal
history and any other matter necessary for licensing. By my signature I certify that the provided information
is accurate to the best of my knowledge.

Signature:                                              Title:                                 Date:
Rev. 8/3/10
                                                  Personal Data Form
For a sole proprietorship, the owner must complete this form. For a general partnership, submit the requested information for
each individual with 10% or more interest in the business. For a limited liability partnership or corporation, the president and
vice president must complete the form. The form must be fully completed to expedite processing of your application.

Business Name:
Phone Number: (      )       -
Street Address:

1. Individual’s Full Name:                                     A.K.A.
                                                               (Maiden name, nickname, etc,)
  Street Address:                                              City:                             State:        Zip:       -
  SSN:      -    -                                             Date of Birth:  /   /
  Relationship to Above Business:


2. Individual’s Full Name:                                     A.K.A.
                                                               (Maiden name, nickname, etc,)
  Street Address:                                              City:                             State:        Zip:       -
  SSN:      -     -                                            Date of Birth:  /   /
  Relationship to Above Business:


3. Individual’s Full Name:                                     A.K.A.
                                                               (Maiden name, nickname, etc,)
  Street Address:                                              City:                             State:        Zip:       -
  SSN:      -    -                                             Date of Birth:  /   /
  Relationship to Above Business:


4. Individual’s Full Name:                                     A.K.A.
                                                               (Maiden name, nickname, etc,)
  Street Address:                                              City:                             State:        Zip:       -
  SSN:      -    -                                             Date of Birth: /    /
  Relationship to Business:


*By my signature I authorize the Montana Lottery to investigate my financial background, criminal history and/or any
other matter necessary for licensing. I certify that I have read the Conditions of Licensing and agree to comply with
those conditions.

Rev. 8/3/10
                       Electronic Funds Transfer (EFT) Authorization

Retailer Number: (For Lottery Use Only)
Retailer Name:
I hereby authorize the Montana Lottery to initiate debit/credit entries into my (check one of the following):
                                Checking Account             or             Savings Account
indicated below, and the Financial Institution below, to debit/credit same to such account.
Financial Institution:
City:                                                       State:               Zip:
Account No.
This authority is to remain in full force and effect until the Montana Lottery and my Financial Institution have
received written notification from me of its termination in such time and in such manner as to afford the Montana
Lottery and my Financial Institution a reasonable time to act on it.
(Circle One) Owner / Partner / Duly Authorized Officer

          Signature of Owner Partner or Corporate Governing Officer   Title                 Date
Substitute Form
                                     REQUEST FOR TAXPAYER IDENTIFICATION
  W-9                                     NUMBER (TIN) VERIFICATION                                                                        State of Montana
                                                                                                                                           Do NOT send to IRS
PRINT OR TYPE                                                                                                              RETURN TO ADDRESS BELOW


Remit Address

Purchase Order Address – Optional
                                                                                                                           PART II See Part II Instruction on Back of Form

Check legal entity type and enter 9 digit Taxpayer Identification Number (TIN) below:                                      Do Not enter an SSN or EIN that was not
(SSN = Social Security Number EIN = Employer Identification Number)                                                        assigned to the legal name entered above
   Individual                                                       (Individual’s SSN)
NOTE: If no name is circled on a Joint Account when there is more then one name, the number will be considered to be that of the first name listed.
    Sole Proprietorship (Owner’s SSN or Business FEIN)                                                     SSN
NOTE: Enter both the owner’s SSN and the Business EIN (if you are required to have one)
                                                                                                       EIN                      EFFECTIVE DATE OF EIN
    Partnership                     General         Limited                             (Partnership’s EIN)
                                                                                                                                EFFECTIVE DATE OF EIN
    Estate / Trust                                                                     (Legal Entity’s EIN)
NOTE: Do not furnish the identification number of personal representative or trustee unless the legal entity itself is not designated in
     the account title. List and circle the name of the legal trust, estate or pension trust.                                       EFFECTIVE DATE OF EIN
    Other       Please specify                                                                 (Entity’s EIN)
    Limited Liability Company, Joint Venture, Club, etc.                                                                         EFFECTIVE DATE OF EIN
    Corporation         Do you provide legal or medical services?     Yes     No                (Corp’s EIN)
     Includes corporations providing medical billing services                                                                   EFFECTIVE DATE OF EIN
    Government            (or Government Operated) Entity                                       (Entity’s EIN)
                                                                                                                                 EFFECTIVE DATE OF EIN
    Organization Exempt from Tax under Section 501(a)                                              (Org’s EIN)
     Do you provide medical services?     Yes        No                                                                          EFFECTIVE DATE OF EIN
    Check here if you do not have a SSN or EIN, but have applied for one. See reverse for information on How to Obtain a TIN.
     Licensed Real Estate Broker?       Yes     No
     Exempt from backup withholding?          Yes     No

     Under Penalties of perjury, I certify that:
1. The number listed on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me) AND
2. I am n ot su bject to b ackup wi thholding b ecause: (a) I am ex empt from backup withholding, o r ( b) I hav e n ot be en n otified by t he In ternal Revenue
service (IRS) that I am su bject to backup withholding as a result of a failure to report all interest or dividends’ or (C) the IRS has notified me that I am no
longer su bject t o backu p wit hholding (do es n ot apply to re al es tate transactions, mortgage inte rest paid, the acquisition of ab andonment o f se cured
property, contribution to an individual retirement arrangement (IRA), and payments other than interest and dividends).
CERTIFICATION INSTRUCTIONS – Yo u must cross out item (2) a bove i f you have been notified b y t he I RS th at you a re currently subject to
backup withholding because of under reporting interest or dividends on your tax return. (See Signing the Certification on the reverse of this form.)

Name (Print or Type)                                                                  Title (Print or Type)
Signature of U.S. Person                                                              Date                                 Phone(         )
E-Mail Address (Print or Type)

DO NOT WRITE BELOW THIS LINE                                                                                               RETURN TO ADDRESS ABOVE

                                                                    AGENCY USE ONLY
Agency                                                    Approved By                                                      Date
1099 Yes No
Vendor Addition               Change                      Action Completed By                                              Date

615-82-50-7093 (R 2/06)

             INDIVIDUALS: Enter First and Last name EXACTLY as it ap pears on your So cial Security Card. However, if you have changed your last
             name, for in stance, due to marriage, without informing the S ocial Security Administration of th e name change, please enter your first name
             and both the last name shown on your social security card and your new last name (IN THAT ORDER). For your TIN, enter your Social

             Security Number (SSN).
             SOLE PROPRIETORSHIPS: Enter the owner’s name on the first line; on the second name line you may enter the business name. YOU
             MAY NOT ENTER ONLY THE BUSINESS NAME. For the TIN, enter both the owner’s Social Security Number and the Federal Employer Tax
             Identification Number (EIN) if you are required to have one.
             ALL OTHER ENTITIES: Enter the name of the owner of the EIN or SSN exactly as originally registered with the IRS. The correct TIN is
             the Employer Identification Number (EIN).

                                  DO NOT ENTER AN SSN OR EIN THAT WAS NOT ASSIGNED TO THE
                                                 LEGAL NAME OF THIS FORM

If you do not have a TIN, you should apply for one immediately. To apply for the number, obtain Form SS-05, Application for a S ocial Security Number
Card (for individuals), or Form SS-4, Application of Employer Identification number (for businesses and all other entities), at your local office of the Social
Security Administration or the Internal Revenue Service. Complete and file the appropriate form according to its instructions.
To complete Form W-9 if you do not have a TIN, check “Applied For” box in the space indicated on the f ront, sign and date the f orm, and give it to the
requester. For payments that could be subject to backup withholding, you will then have 60 days to obtain a TIN and furnish it to the requester. During the
60-day period, the payments you receive will not be subject to the 31% backup withholding, unless you make a withdrawal. However, if the requester does
not receive your TIN from you within 60 days, backup withholding, if applicable, will begin and continue until you furnish your TIN to the requester.

NOTE: Writing “Applied For” on the form means that you have already applied for a TIN OR that you intend to apply for one in the near future.
As soon as you receive your TIN, complete another Form W-9, include your new TIN, sign and date the form, and give it to the requester.

                                    FOR PAYEES EXEMPT FROM BACKUP WITHHOLDING
             Individuals (in cluding sole prop rietors) ar e n ot exempt f rom backup withholding. Corporations are exempt from backup withholding for

             certain payments, such as interest and dividends.
             If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. Enter your
             correct TIN in Part I, write ‘Exempt’ in Part II and sign and date the form.
             If you are a nonr esident alie n or f oreign e ntity n ot subject to backup withho lding, g ive the r equester a co mpleted F orm W -8, C ertificate of
             Foreign Status.

             1) Interest, Dividend, and Barter Exchange Accounts Opened Before 1984 and Broker Accounts That Were
             Considered Active During 1983. – You are not required to sign the certification; however, you may do so. You are required to provide
             your correct TIN.
             (2) Interest, Dividend, Broker and Barter Exchange Accounts Opened After 1983 and Broker Accounts That
             Were Considered Inactive During 1983. – You must sign the certification or backup withholding will apply. If you are subject to

             backup withholding and you are merely providing your co rrect TIN to the requester, you mu st cross out item (2) in the certification before
             signing the form.
             (3) Real Estate Transactions – You must sign the certification. You may cross out item (2) of the certification if you wish.
             (4) Other Payments – Yo u are required to fu rnish yo ur correct TIN, but yo u are not requi red to sign the ce rtification unless yo u have
             been n otified o f an in correct TI N. Oth er pa yments in clude payments ma de in the course of t he r equester’s tra de o r business f or rents,
             royalties, g oods (other th an bi lls fo r merchandise), m edical and heath care services, pa yments t o a n onemployee fo r s ervices (i ncluding
             attorney and accounting fees), and payments to certain fishing boat crew members.
             (5) Mortgage Interest Paid by You, Acquisition or Abandonment of Secured Property, or IRA Contributions.
             – You are required to furnish your correct TIN, but not required to sign the certification.

             Signature. – The signature should be an authorized signature, generally the person whose name is on the top line of the form, a partner
                          in the partnership, or an officer of the corporation. For joint account, only the person whose TIN is shown in LEGAL
                          BUSINESS DESIGNATION should sign the form.
             Privacy Act Notice. – Section 6109 requires you to furnish your correct taxpayer identification number (TI N) to per sons who must file

             information returns w ith t he IR S to repo rt in terest, di vidends, and c ertain o ther in come pa id t o yo u, mo rtgage in terest you pa id, th e
             acquisition or aband onment of sec ured p roperty, or c ontributions you ma de to an individual r etirement a rrangement (IRA). I RS u ses t he
             numbers fo r i dentification pu rposes an d to h elp verify a ccuracy of yo ur ta x return. Yo u mu st p rovide yo ur TI N whether o r n ot you are
             required to file a tax return. Payers must generally withhold 31% of taxable interest, dividend, and certain other payments to a payee who does
             not furnish a TIN to a payer. Certain other penalties may also apply.

    1.          What is Electronic Funds Transfer (EFT)?

                EFT is a process by which an account can be automatically debited and/or credited (once permission is
                obtained from the depositor) without having to write and mail a check. The system is precise because it
                utilizes the telecommunications network of the Federal Reserve to link your bank with the Montana
                Lottery’s bank. An Automated Clearing House (ACH) acts as a middleman to route funds to the proper

    2.          What are the advantages in using the EFT system?

                A) You are assured the funds are received.
                B) You will know exactly when your account will be debited. The transaction will occur at the same
                   time every collection cycle.
                C) The cost of writing and mailing a check is eliminated.

    3.          Do I have to participate in EFT?

                All Montana Lottery retailers are required to participate in the system.

    4.          Is a separate Lottery account advisable?

                This decision will be left to you. Whatever is easiest for you is fine with us. If you choose to open a
                separate account for the EFT transfers, you will be able to keep the Lottery transactions separate from
                your regular account, but your bank may charge extra for maintaining a separate account. You should
                discuss that with your bank.

    5.          Can I use my present bank for EFT?

                In most cases, yes. However, in Montana, there are still a few banks that have difficulty handling EFT.
                You should contact your bank to determine if there may be a problem with using your present account.

    6.          What steps do I take with my bank so I can participate in the EFT system?

                Simply open a bank account (or use an existing account) and make your bank aware there will be
                EFT transactions processed against your account. Notify the Lottery of your account number and
                transit routing number by completing and returning the EFT Authorization Form with your Retailer

    7.          Whose name should be on the account?

                You should use the business name exactly as it appears on your Montana Lottery Retailer Application.

    8.          How much will it cost for this service?

                The transaction charges and/or service charges Lottery retailers pay vary with different banks. In most
                cases these charges have been reasonable.

                Your bank charges should be considered when determining how much money to deposit in an account
                to cover the EFT sweep.

    9.          Can I earn interest on this account?

                You should check with your bank regarding the feasibility of using an interest bearing account.

Rev. 8/3/2010
    10.         Can this account be used by the Lottery to monitor my account?

                The Lottery can only debit or credit your account. The Lottery has no way of monitoring your activity or balances.

    11.         How do I know when my account will be swept and for how much?

                Your account will be swept weekly for all monies due from the prior accounting week (Sunday through
                Saturday). Each Wednesday morning your lottery terminal will produce a settlement report for the prior
                accounting week. This report shows the total amount of your weekly sweep.

    12.         When must my money be deposited in the EFT account for transfer to the Lottery?

                You should deposit the money into your EFT Account no later than 3 p.m. on Wednesday.

    13.         What will happen if the proper amount of money is not in my EFT account at the time the
                transfer to the Lottery is effected?

                Even if your EFT account is just one cent short of having enough money at the time of the EFT
                transfer, the entire transaction will be returned to us as a Non-Sufficient Funds (NSF). The Lottery has
                established the following policy for handling NSF.

                When the first NSF is received from Federal Reserve, you will be contacted and asked to send us a cashier’s
                check or money order to cover the NSF.

                If we receive a second NSF notice from Federal Reserve, we may automatically inactivate your lottery
                terminal until payment in full is received. This procedure will stop all orders and deliveries until your
                lottery terminal is reactivated. We will then review your payment history and take appropriate action,
                which could include revocation of your Lottery retailer license.

                Any non-sufficient fund (NSF) charges assessed by your bank will be your responsibility.

    14.         What do I do if I have a problem with my invoice but don’t want to risk the Lottery getting a NSF

                Immediately call Lottery Accounting on our toll free number, 1-800-443-5708, to discuss the problem. A
                determination will be made at that time regarding payment.

    15.         Can third party checks be deposited to the EFT account?

                Checks can take a number of days to clear and become “available money.” If checks are deposited into
                the EFT account, you should take into consideration that it could be several days before monies are
                available for EFT sweeps.

    16.         Can I pay winning tickets with checks drawn against the EFT account?

                Yes. Just be sure that checks written do not draw your account balance below the amount required for
                your next EFT sweep.

    17.         Who do I call if I have a problem with the EFT system?

                If you experience a problem with the EFT system, contact Lottery Accounting on our toll free number,

    18.         What do I do if I need to change my EFT account?

                If you need to change your EFT account, please contact Lottery Accounting on our toll free number,
                1-800-443-5708, at least two weeks in advance. You will need to complete the Change in EFT Account
                Authorization form.

Rev. 8/3/2010

          Local Business, Inc.

            A Street NW



To top