Florida Lottery Dol 129 Form – Fill Out and Use This PDF

	Florida Lottery	ID#___ CHAIN#___
	250 Marriott Drive
		PROSPECT#______
	Tallahassee, FL 32399-6573
	(850) 487-7714 or flalottery.com	DO___________

Non-refundable Application Fee: Payable to the Florida Lottery by check or money order.

Initial Application $100, Additional Location $25, Change of Location $10,

New Officer, Director or Shareholder $25 each.

Each applicant shall be subject to a background investigation which can include fingerprinting.

A retailer applicant shall be required to post a bond, certificate of deposit or other security if it is determined during the background

investigation that such requirement is necessary to secure payment of lottery proceeds.

Check application type and complete the information below - PLEASE PRINT OR TYPE:

0 INITIAL APPLICATION O100% SALE OF STOCK O NEW OFFICER(S), DIRECTOR(S), SHAREHOLDER(S) 0 ADDITIONAL STORE LOCATION

0 CHANGE OF LOCATION: Date of Relocation ____________

0 CHANGE OF OWNERSHIP: Previous Location ID#___________ Date of Sale _______

For information concerning sale of business: Contact Name ________ Phone Number ( ___

SECTION 1 - BUSINESS INFORMATION

1.CORPORATE OR OTHER LEGAL NAME: ________________________

2.STORE NAME (dba): _______________ 3. STORE PHONE: { __ } __ - ___

4.STORE ADDRESS: _______________________________

StreetCityState Zip Code County

			_
5. MAILING ADDRESS: _____________________________
SameasStoreAddressO Street or P.O. Box	City	State	Zip Code
6. CONTACT NAME AND TITLE: ___________________________
First	Middle Initial	Last	Title
7. CONTACT NUMBERS AND E-MAIL ADDRESS:			{ __} __-____
{ __} __-____	{ __} __- ____
Phone	Alternate Phone		Fax Number

E-mail Address

8.TAXPAYER IDENTIFICATION NUMBER: Provide number used to file business income tax return.

Sole Proprietors, list Social Security Number. All other entities, list Federal Employer Identification Number.

9.FLORIDA SALES TAX NUMBER: _ _ - _ _ _ _ _ _ _ _ _ _ - _ 0 Applied For O Tax Exempt

10. ALCOHOLIC BEVERAGE LICENSE NUMBER: __-_____				0 Applied For O Not Applicable
11.	MINORITY BUSINESS: 0 YES	ONO (If yes, check appropriate minority category)
	African American	Native American		_ Hispanic American
	American Woman	Asian American
12.	BUSINESS TYPE: (Check One)	_ Partnership	Non Profit	_ Sole Proprietorship
	_ Corporation
	_ Limited Partnership	_ Limited Liability Company	_ Limited Liability Partnership
13.	FLORIDA DEPT. OF STATE, DIVISION OF CORPORATIONS DOCUMENT NUMBER: ____________

DOL-129 (Revised 4/19)

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SECTION 2 - OFFICER/OWNER INFORMATION

THE LOTTERY SHALL NOT CONTRACT WITH ANY PERSON WHO IS RELATED TO AND RESIDING WITH ANY EMPLOYEE OF THE LOTTERY.

1.Are any of the individuals listed below related to an employee of the Florida Lottery in one of the following ways: husband, wife, parent, grandparent, spouse's parent, child, brother, sister, spouse of a child, aunt, uncle, grandchild, niece, nephew, first cousin, and living in the same household as the employee? ____ Yes ___No

2.LIST ALL OWNERS, INDIVIDUAL PARTNERS, MANAGING MEMBERS, CORPORATE OFFICERS, DIRECTORS. LIST

SHARE-HOLDERS OF 10% OR MORE OR LIMITED PARTNERS WITH 10% OR MORE INTEREST IN THE BUSINESS. IF MORE SPACE IS REQUIRED, PLEASE ATTACH ADDITIONAL SHEETS.

Name (first, middle initial, last)		Phone		Title			Birthdate (MM-DD-YY)
Home Address	City	State	Zip	Sex	Race	% Ownership	Social Security Number
Name (first, middle initial, last)		Phone		Title			Birthdate (MM-DD-YY)
Home Address	City	State	Zip	Sex	Race	% Ownership	Social Security Number
Name {first, middle initial, last)		Phone		Title			Birthdate (MM-DD-YY)
Home Address	City	State	Zip	Sex	Race	% Ownership	Social Security Number
Name {first, middle initial, last)		Phone		Title			Birthdate (MM-DD-YY)
Home Address	City	State	Zip	Sex	Race	% Ownership	Social Security Number
Name (first, middle initial, last)		Phone		Title			Birthdate (MM-DD-YY)
Home Address	City	State	Zip	Sex	Race	% Ownership	Social Security Number

c. Been arrested and have any pending criminal charges that have not been resolved?	Yes	No
d. Been a Florida Lottery Retailer?	Yes	No
e. Been suspended or terminated as a Florida Lottery Retailer?	Yes	No
f. Been subject to any adverse actions or findings as a lottery retailer with any other state lottery within
the continental United States?	Yes	No

If yes to questions a, b, c, d, e, or f, please explain response and include dates below (use additional sheet if necessary).

DOL-129 (Revised 4/19)

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4.For any individuals listed in the Officer/Owner Information, Section 2, who are not U.S. citizens, please list the individual's name, mother's maiden name, father's name; passport number, permanent resident or 1-94 number; the last permanent address prior to entering the U.S. and the last date of entry into the U.S.

How did you learn about becoming a Florida Lottery Retailer? Check one:					D Sales Rep Visit
D Florida Lottery Website	D Word of Mouth		D Direct Mail	D Print Ad
D Florida Business Information Portal		D Other: Please Specify

Certification:

An attorney in fact may not make any affidavit as to the personal knowledge of the principal.

I HEREBY CERTIFY that the information contained on this form or otherwise submitted to the Florida Lottery in connection with my application to become a retailer is true and correct in every material respect. I understand that providing inaccurate or misleading information is grounds for rejection of this application or cancellation of the Retailer Contract. The Florida Lottery is authorized to obtain criminal background, Florida tax, credit, and general information about me, my business, and any persons listed on this application, which may assist in making a decision on this application. The business location where lottery tickets will be sold is in compliance with the accessibility requirements set forth in sections 553.501 - 553.513, Fla. Stat., the Florida Americans with Disabilities Accessibility Implementation Act.

I HEREBY CERTIFY I have read and understand the content contained in the Retailer Awareness and Integrity Training document found on the Florida Lottery's website at flalottery.com/HowToApply.

State of _______________

Signature of Authorized Corporate Officer, Partner, or Owner

	County of _______________
	Sworn to or affirmed and subscribed before me this
Print or type name	________ day of ______, ___,
		(Day)	(Month)	(Year)
Title	by _______________
		(Name of Authorized Corporate Officer, Partner, or Owner)
	Signature of Notary Public
		(Print, Type or Stamp Commissioned Name of Notary Public)
	__ Personally Known or __ Produced Identification
	Type of
Affix Notary stamp above.	Identification ______________

Certificates of Authority and retailer contracts are not assignable or transferable between persons or locations. STATEMENT OF PUBLIC DISCLOSURE: Information contained in this application shall be open to the public for inspection.

DOL-129 (Revised 4/19)

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MARKETING EVALUATION/SITE SURVEY

Store Name: ---------------- COMPLETE WITH LOTTERY SALES REPRESENTATIVE

1.TRADE STYLE (Circle One)

Airport Location	Convenience Store­		Hardware/Building Supplies			Restaurant - No Liquor
Appliances	no gas pumps		Hotel/Motel			Shopping Mall Location
Auto Parts/Repair	Convenience Store-		Ice Cream Shop			Small Grocery/Meat/Fish Market
Bakery	with gas pumps		Jewelry Store			Sports Arena/Amusement Park
Bar/Tavern/Lounge	Department Store		Laundry/Dry Cleaner			Supermarket
Barber Shop/Hairdresser	Dollar Store/Discount Store		Mail Services/Copy Center			Telecommunications Center
Beauty Shop	Drug Store/Pharmacy		Municipality/Political Subdivision			Travel Agency
Bingo Hall	Financial Services		Newsstand/Tobacconist/Sundries			Travel Plaza/Truck Stop
Bowling Alley	Flea Market		Non-Profit Organization			Wholesale Club
Car Wash	Florist		Package Liquor Store			Other ________
Clothing/Shoes	Gas Station/Auto Repair		Pari-Mutuel
Coffee/Deli/Sub Shop	Gift/Card Shop		Restaurant - Liquor
2. BUSINESS OPERATION:		0 SEASONAL BUSINESS		0 YEAR-ROUND BUSINESS
Business Hours	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY	SATURDAY	SUNDAY
FROM
TO

3. RETAILER INSTALLATION INFORMATION:	■ Yes	■ No
New Construction or Store Not Yet Open? Please Check.
If yes, complete a, b, & c below.

a. Store opening date:___________

b. Approximate date for terminal and communications equipment installation:__________

c. Building contact name and phone number: _____________________
Retailer Owns Location? Please Check.	■ Yes	■ No

If no, complete a & b below.

Retailers with a lease agreement must have their landlord's approval for the installation of communications equipment on the roof and the installation of cables inside the location.

a.Landlord contact name:---------------------------------

b.Landlord phone number:_________________________________

4.COMMENTS:

Sales Representative: -----------------------------------

Lottery Sales Representative Signature		SR#		Stop#			Date
Lottery District Manager:

Lottery District Manager Signature

Date

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DOL-129 (Revised 4/19)

PRIVACY ACT NOTICE

RETAILER APPLICANTS

Under the Federal Privacy Act, disclosure of a person's Social Security number is voluntary unless a Federal statute specifically requires such disclosure or allows states to collect the number. In connection with filing an application to become a Florida Lottery retailer, disclosure of the applicant's Social Securtiy number is required by 26 U.S.C.A. s. 6109 for tax reporting purposes. The applicant's Social Security number will also be used in performing the background investigation necessary to implement Section 24.112, Florida Statutes, because the Social Security number is used as an identifier in the databases searched.

The Lottery may also provide this information to law enforcement agencies to enforce criminal laws.

Under Section 119.071(5), Florida Statutes, an agency may collect Social Security numbers if it is imperative for the performance of the agency's duties and responsibilities. Notice is hereby provided that for retailer applicants that are legal entities, it is imperative that the Lottery use the Social Security numbers of members, partners, officers, directors, etc., to conduct the background investigations necessary to implement Section 24.112, Florida Statutes, because the Social Security number is used as an identifier in the databases searched.

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DOL-129 (Revised 4/19)