Illinois Lottery Retailer Application Packet

More documents

Recommendations

Info

IDL-30 Retailer Contractfor Sale of Lottery TicketsNote: The Illinois Department of the Lottery is requesting disclosure of information that is necessary to accomplish the statutory purpose asoutlined under 20 ILCS 1605 to process your Lottery License. Disclosure of this information is voluntary. However, failure to comply may result inthis form not being accepted. False or misleading statements on the application may be cause for rejection or revocation of a Retailer’s License.Step 1: Complete the applicant’s business contact information and details.Business Contact InformationBusiness NameCorporate Name (if applicable)Business AddressProperty listed here isOwned RentedCity State ZIP CountyBusiness Phone Business Fax Corporate Phone Corporate FaxContact NameE-mailMailing Address (if different from above)City State ZIP CountyDeliver Instant Tickets toBusiness AddressMailing AddressBusiness Type and DetailsSelect one of the four business types, then indicate how you report for federal tax purposes.Sole proprietorshipPartnership (P)Corporation (C)Limited Liability CompanyUse FEIN (F)Use SSN (S)Limited PartnershipNot For Profit CorporationTreated as a:Partnership (P)Corporation (C)Single Member LLC (C)Illinois Business Tax Number (IBT)FEIN (Also complete and attach Form W-9)Is the retailer location a franchisee?Yes NoProducts sold or types of service providedBusiness HoursMondayTuesdayWednesdayThursdayFridaySaturdaySundaytototototototoLottery Use OnlyRetailer Number Region County Code LSR BDACC Chain HQ Central Bill KOBChange of OwnershipYes NoPrevious Retailer Number Previous Retailer Name If LLC, FEIN Assignment Letter provided?Yes NoDate of Initial Visit Date of Final Visit Total Visits Address and SSN Confirmed by LicensingYes NoPrevious Owner Debt Checklist Required?Yes NoLicensing requires all BDAs to contact the Lottery Licensing department before submitting applications to confirm there was no previousowner at the location that still has debt with the Lottery. If there is previous owner debt, checklist will have to be completed.Lottery Approval Signature, Superintendent of the Illinois Department of the LotteryLottery Approval DateIDL-30 Retailer Contract for Sale of Lottery Tickets (R 07-2013)
Step 2: Complete the certification and signature authorization.Sole Proprietorship – The owner must complete and signSection A. If it is a husband and wife sole proprietorship,complete Sections A and B, one for each spouse.Corporations – Every corporate officer must completeand sign one section.Partnerships – Each general partner must complete andsign one section.Limited Liability Companies – One of the three options inIDL-30 Page 1, Step 1, Business Type and Details, musthave been selected and IRS FEIN Assignment Letter mustbe provided. Each member must complete and sign onesection, unless such authority has been solely delegatedto a manager, in which case you must also furnish themanager’s information and a copy of the articles oforganization or operating agreement to support themanager’s authority to sign this document.Each of the undersigned certifies that:A. I have read and understand this IDL-30 Retailer Contract for theSale of Lottery Tickets and its companion document, the RetailerAgreement for Sale of Lottery Tickets, and agree, individuallyand as authorized agent of the applicant, and on behalf of theowners, partners, members or officers of the applicant, to theterms and conditions of both documents, and was given a copyfor my records.B. Under penalty of perjury, I am no more than 30 days delinquentin complying with a child support order. (Please note that failureto certify will result in a denial of your License, and that falsecertification may also result in denial of your License or subjectyou to contempt of court.)C. In the case of an applicant that is not an individual I acknowledgethat the owners, partners, and members, may be held personallyliable for any amounts owed to the Lottery and any Lottery receipts,which, in either case, are not segregated and kept separate andapart from the applicant or retailer other funds and paid to theLottery when due, and hereby accept this responsibility individuallyif I am an owner, partner or member, or on behalf of the owners,partners or members if I am a manager or officer to whom authorityhas been delegated by the owners, partners or members.D. In the case of a corporate applicant, I acknowledge that if I am anofficer of the corporation I may be held personally liable for anyamounts owed to the Lottery and any Lottery receipts, which, ineither case, are not segregated and kept separate and apart fromthe corporate funds and paid to the Lottery when due, and herebyaccept this responsibility.E. I personally, and on behalf of each owner, partner, member, manageror officer listed on the application, authorize the Lottery to obtainfrom the Illinois Department of State Police, the Illinois Department ofRevenue, other government agencies and any reputable consumercredit reporting services, all information contained in their recordsconcerning the business, each owner, partner and officer including therelease of criminal history information, taxpayer identification numbers,driver’s license numbers and credit history. I release any individual,organization or agency from any and all liability incurred as a result ofproviding such records.Write the owner, officer, member or partner information, completing one entire section for each person. If you have more than two persons,please complete and attach Additional Signatures page. All owners/officers/partners/members must be at least 18 years old.ALast Name First Name MI Job Title % OwnershipHome Street AddressCity State ZIP CountyProperty listed here isOwned RentedSSN Spouse’s SSN Date of BirthSexMaleFemaleRace (optional)Driver’s License NumberHome Phone Mobile Phone Alternate PhoneSignatureDateBLast Name First Name MI Job Title % OwnershipHome Street AddressCity State ZIP CountyProperty listed here isOwned RentedSSN Spouse’s SSN Date of BirthSexMaleFemaleRace (optional)Driver’s License NumberHome Phone Mobile Phone Alternate PhoneSignatureDateStep 3: Attach check, made out to Illinois Lottery, for $50 application fee.IDL-30 Retailer Contract for Sale of Lottery Tickets (R 07-2013)
Page 1 and 2: Retailer Agreementfor Sale of Lotte
Page 3: Retailer Agreement for Sale of Lott
Page 7 and 8: Additional Signatures: Retailer Con
Page 10: Instructions for Completing W-9 For

Illinois Lottery Retailer Application Packet

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?