Ga Lottery Application – Fill Out and Use This PDF

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Ga Lottery Application PDF Details

Did you know that the State of Georgia offers a variety of lottery games? If you're interested in playing, you'll need to complete a Ga Lottery application form. In this article, we'll provide step-by-step instructions on how to submit your application. We'll also tell you what you need to know about the different lottery games available.

Below is the details in regards to the file you were seeking to fill out. It will tell you the time it may need to complete ga lottery application, what fields you need to fill in, and so on.

Question	Answer
Form Name	Ga Lottery Application
Form Length	10 pages
Fillable?	Yes
Fillable fields	183
Avg. time to fill out	39 min 10 sec
Other names	georgia lottery claim form printable, georgia lottery application, georgia lottery application form, ga lottery claim form individual

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GEORGIA LOTTERY CORPORATION

Instructions for Retailer Application Packet

1-800-746-8546 - OPTION #4 - Retailer Contracts Administration

PART 1 - Business Information

The application to become a Georgia Lottery Retailer must be accompanied by a Cashier’s Check, Business Check or Money Order for $125 per business location. (In the event the application for a business location is not approved by the Georgia Lottery Corporation, $100 of the $125 will be refunded.)

Line 1 - List the name of the entity which owns the business and iles Income tax returns.

Line 2 - List the name of the business where tickets are to be sold.

Line 3 - 8 - List the business address, business telephone #, city, state, zip, & county

Lines 9 - 12 - List the mailing address, if different from #3 above: otherwise, please leave this blank.

Line 13 - List fax number, if applicable.

Line 14 - List each Principal of the Business. Please attach additional sheets as needed. EACH LISTED INDIVIDUAL MUST ALSO COMPLETE PART 2 OF THIS APPLICATION.

Line 15 - Complete, sign and have this statement notarized.

Line 16 - Business Contacts – Name, title, and phone number of the person(s) the Lottery should contact on all Lottery business.

Line 17 - Optional - If the majority ownership (more than 50%) of the business is held by a person or persons of a minority race, it is requested, but not mandatory, that this section be completed.

Minority Business Ownership is deined in Georgia statutes as

follows:

•For a proprietorship: A business owned by “an individual who is

a member of a minority who reports as his personal income for

Georgia Income tax purposes the income of such business”; or

•For a partnership: “A partnership in which a majority of the

ownership interest is owned by one or more members of a minority who report as their personal income for Georgia income tax purposes more than 50 percent of the income of the partnership”;

•For a corporation: “A corporation organized under the laws of this state in which a majority of the common stock is owned by

one or more members of a minority who report as their personal income for Georgia Income tax purposes more than 50 percent of the distributed earnings of the corporation.”

Line 18 - Business Hours - List business hours for Sunday through Saturday.

LOTTERY OFFICIAL TO COMPLETE ALL SHADED ENTRIES

PART 2 - Personal Information (Owner)

This form must be completed for each owner, shareholder, member, and oficer of the business. Make additional copies

if necessary.

Lines 1 - 14 - List all information requested.

Line 15 - If answering “yes” to any of these questions, please explain on a separate sheet and attach to this application.

Lines 16 - 21 - List all information requested.

Line 22 - Attach a copy of one of the following forms of identiication (Driver's License, Georgia Identiication Card, Identiication Card issued by another state, U.S. Armed Forces Identiication Card, U.S. Passport or U.S. Resident Alien Card).

Line 23 - Complete, sign and have this statement notarized.

PART 3 - Electronic Funds Transfer Authorization

Line 1 - List the name of the entity which owns the business and iles Income tax returns.

Lines 2 - 4 - Obtain and list required licensing numbers from the Georgia Department of Revenue (State Tax Identiier, Sales Tax, & Alcohol).

Line 5 - The Federal Employers ID Number (FEIN) must be listed

for partnerships and corporations. Sole proprietors must list the social security number only.

Line 6 - List all information requested and sign the authorization.

Line 7 - Must be completed and signed by Depository Institution

Representative.

This veriies the establishment of an account “In Trust for the Georgia Lottery Corporation.” Attached is a letter to provide to your Bank Representative which provides an example of the account title requirements.

PART 4 - Retailer Contract

A Contract must also be completed by each member of an LLC or Partnership. Make additional copies if necessary.

Complete and sign page 2 of the Retailer Contract.

Business Trade Styles

Auto Supply				Restaurants (Non-Fast Food)
Bar/Lounge/ Tavern	Convenience/Gas	Hotels & Other Lodging	Other Non-retail	Service/Gas Station
Bowling Center	Discount Department Stores	Independent/Grocery Store	Other Retail	Stationery/Gift/Newsstand
Check Cashing	Drug Store/Pharmacy	Major Supermarket Stores	Package Store	Value Stores
Coffee Houses	Fraternal Organizations	Mall Kiosk	Restaurant	Video Store
Convenience	Home Improvement	Not Classiied	Restaurant/Truck Stop

Revised 3/12/13

	Retailer Application
	GEORGIA LOTTERY CORPORATION		1 of 3
	P.O. Box 56486 • Atlanta, GA 30343
1-800-746-8546 - OPTION #4 - Retailer Contracts Administration
Please submit completed application with $125 fee per business location
	(Cashier’s Check, Business Check, or Money Order only).
PART 1 - Business Information	PLEASE PRINT	Lottery Retailer ID#:

1.Corporate or legal name (List the name of the legal entity which owns the business and iles income tax returns):

2.Store Name or d/b/a (list the name of the business where tickets are to be sold):

3.	Business Location:	(Street Number and Name of the location where lottery tickets are to be sold)		4. Business Telephone Number:

5.	City:	6. State:	7. Zip Code:	8. County:

9. Mailing Address (if different) (P.O. Box Number or Street Number and Name) :

10. City:

11. State:

12. Zip Code:

13. Fax Number:

14.List each owner, shareholder, member and oficer of the Business (for example, sole proprietors, general partners, corporate oficers, directors and shareholders). EACh LISTED INDIvIDUAL MUST COMPLETE PART 2 OF ThIS FORM. Please attach additional sheets as needed:

a. Name:				Percent of Ownership:
b. Name:				Percent of Ownership:
c. Name:				Percent of Ownership:
d. Name:				Percent of Ownership:

15.Applicant certiies that the information contained on this form or otherwise submitted to the Georgia Lottery Corporation (“GLC”) in connection with this application to become a Retailer is true and correct in every respect. The undersigned certiies that he is duly authorized to act on behalf

of the Retailer Applicant. Applicant understands, agrees, and consents that the GLC may make any and all investigations necessary in order to

satisfy the GLC requirements for qualiication of the Applicant as a GLC Retailer. Applicant hereby authorizes GLC to request criminal history record

information, a credit report, or conduct any other investigation as may be necessary to process Applicant’s request to become a GLC Retailer.

Applicant authorizes GLC to share any such information, privileged, conidential or otherwise, necessary to consider its application to become a GLC Retailer. Applicant further consents to allow GLC to use and share such information in all manner consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out of the relationship between Applicant and GLC. Applicant understands that providing inaccurate or misleading information is grounds for rejection of this application or cancellation of the Retailer Contract, and may subject the Applicant to the penalties set forth in O.C.G.A. §50-27-28.

Signature of Owner or Principal

Print or Type Name

Title

Date

NOTARY

STATE OF:

COUNTY OF:

SWORN TO AND SUBSCRIBED BEFORE ME ON ThIS

DAY OF

(MONTh)

(YEAR)

Notary Public Seal and Signature:

My Commission Expires:

Personal Identiication (ID) is required to be presented to and veriied by Notary Public. Type of ID:

ID Number:

16. Business Contacts (Persons Authorized to Conduct On-Site Lottery Transactions):			Cell Phone #
	Name	Title/Function	Cell Phone #
a.
b.
c.

17. (OPTIONAL) Is Business Ownership more than 50% of a minority race?

 Yes

 No

If yes, Specify:  African American

 Native American

 Asian  Hispanic

 Other (specify):

18. Business Hours:

 Sunday

 Monday

 Tuesday

 Wednesday

 Thursday

 Friday

 Saturday

Open

To be completed by Lottery Representative

Business Trade Style: (see Instruction Sheet)

Revised 3/12/13

NOTARY

Retailer Application	2 of 3
GEORGIA LOTTERY CORPORATION	Make additional
P.O. Box 56486 • Atlanta, GA 30343	copies if necessary.
	copies if necessary.

1-800-746-8546 - OPTION #4 - Retailer Contracts Administration

This form must be completed for each owner, shareholder, member, and oficer of the business.

PART 2 - Personal Information (Owner)

PLEASE PRINT

Lottery Retailer ID#:

1. Type of Ownership:

Sole Proprietor

 Partnership

Corporation

 Non-Proit

 LLC (Corporation)

 LLC (Partnership)

 Other(specify):

First, Middle & Last Name of Owner or Principal (no initials):

M or F:

4. Place of Birth:

Title:

Race:

7. Percent of Ownership:

8. Date of Birth:

Home Street Address:

10. City/State/Zip Code:

11. home Phone Number:

12. Cell Phone Number:

13.

Social Security

Number:

14.

E-mail Address:

(

)

(

)

15.

•Do you reside in the same

household as any oficer or

employee of the Georgia Lottery Corporation?

 Yes

 No

•Are you a vendor, employee or agent of any vendor of the Georgia Lottery Corporation?

 Yes

 No

•have you been convicted of a criminal offense related to the security or integrity of the lottery in this or any other jurisdiction? If yes,

where? and when?

 Yes

 No

•have you been convicted of any illegal gambling activity, false statements, false swearing or perjury in this or any other jurisdiction or

convicted of any

crime punishable by more than one year of imprisonment or a ine of more than $1,000.00 or both ?

If yes, where?

and when?

Yes

 No

•Are you delinquent in taxes, fees or other obligations owed to the State of Georgia?

 Yes

 No

•have you iled bankruptcy in the last seven (7) years?

 Yes

 No

Note: If you answered “Yes” to any of the above questions, please explain on a separate sheet and attach to this application.

16.

List all other names you have used, including nicknames; if female, furnish

17. Citizenship

maiden names. If you have ever used any surnames other than your true name,

a. Present citizenship (Country):

during what period and what circumstances were these used? If you have ever legally

b. Citizenship acquired by:

 Birth  Marriage  Naturalization

changed your name, give date, place, and court. (Attach additional page as needed):

c. Naturalization Certiicate Number:

d. Date and place Naturalized:

e. Resident Alien Number:

18. Height:

19. Weight:

20. Hair Color:

21. Eye Color:

22.Attach a copy of one of the following forms of identiication for each owner. The following is a list of acceptable forms of identiication: Driver's License, Georgia Identiication Card, Identiication Card issued by another state, U.S. Armed Forces Identiication Card, U.S. Passport, or U.S. Resident Alien Card.

23.CONSENT AND AUTHORIZATION FOR RELEASE OF PERSONAL BACKGROUND INFORMATION:

I hereby certify that the information contained on this form or otherwise submitted by me to the Georgia Lottery Corporation (“GLC”) in connection

with this application to become a GLC Retailer is true and correct in every respect. I understand, agree and consent that GLC may make any and all investigations of my background in order to satisfy the GLC requirements for qualiication of the Applicant as a GLC Retailer, which investigations may include, without limitation, criminal history record information, credit history records, tax records, public records and other oficial records,

and the investigation generally of any other matter relating to the Applicant being a GLC Retailer. As a potential Retailer or current Retailer for the

Georgia Lottery Corporation (“GLC”), or as an owner of same, I am required to furnish certain information for use in determining my qualiications.

I hereby authorize GLC to request a credit report, conduct a criminal background investigation, or conduct any other investigation as may be necessary to process my Retailer Application to become a GLC Retailer. I authorize GLC to share any such information, privileged, conidential or

otherwise, necessary to consider the application to become a GLC Retailer. I further consent to allow GLC to use and share such information in all manner consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out of the

relationship between the Retailer Applicant and GLC. A photocopy of this release will be valid as an original thereof, even though said photocopy does not contain an original writing of my signature. This release will expire upon the inal termination of my Retailer’s contractual obligations with

the GLC.


Signature			Print Name		Date

The foregoing authorization notwithstanding, for the limited purposes of initially qualifying a Georgia Lottery Retailer, the GLC will not order, as a routine business practice, credit reports or criminal record history reports for individuals owning 10% or less of the equity ownership interests in the Georgia Lottery Retailer applicant. The GLC does reserve the right in its sole discretion to order such reports in accordance with business exigencies.

STATE OF:

COUNTY OF:

SWORN TO AND SUBSCRIBED BEFORE ME ON THIS

DAY OF

(MONTH)

(YEAR)

Notary Public Seal and Signature:

My Commission Expires:

Personal Identiication (ID) is required to be presented to and veriied by Notary Public. Type of ID:

ID Number:

Revised 3/12/13

Retailer Application

GEORGIA LOTTERY CORPORATION	3 of 3
GEORGIA LOTTERY CORPORATION
P.O. Box 56486 • Atlanta, GA 30343
1-800-746-8546 - OPTION #4 - Retailer Contracts Administration

PART 3 - Lottery Retailer Electronic Funds Transfer Authorization Lottery Retailer ID#:

1. Corporate or Legal Name (list the name of the legal entity which owns the business and iles income tax returns):

2. Georgia State Tax Identiier Number (11

3. Georgia Alcohol License Number (if any, 7 digits):

4. Georgia Sales Tax Number (9

Service Business

Only

5.Federal Employers ID Number. 9 digit number used to ile Federal business income tax return. (For Sole Proprietor use Social Security Number)

INSTRUCTIONS: The Retailer must establish a separate electronic funds transfer (EFT) bank account for the preservation and transfer of lottery funds. The separate bank account must be speciied “IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.” The Retailer’s depository institution must conirm the establishment of the Georgia Lottery Corporation Trust Account by signing in the space below.

6.RETAILER AUThORIZATION: I (we) hereby authorize the Georgia Lottery Corporation to initiate debit and credit entries in any available and appropriate amount to my (our) account indicated below and authorize the depository named below to debit or credit the same to such account. I (we) hereby further authorize and direct the depository institution named below to release any information regarding such account, including, but not limited to, account balance information, payment history, and overdraft information to the Georgia Lottery Corporation upon

request by an authorized representative of the Georgia Lottery Corporation. My (our) authorization is given in accordance with subsection

(e)(2) of Section 502 of the “Gramm-Leach-Bliley Act of 1999” (15 U.S.C.A. § 6802) and shall remain in effect until expressly revoked by me (us) in writing. Any such revocation shall be deemed to have been properly given if sent by hand delivery, or by overnight courier, to such

depository institution at the address set forth below. Such revocation shall be deemed to have been delivered on the date of delivery if by hand delivery or if by overnight courier, on the next business day following the deposit of such communication with the overnight courier.

Bank Account Name:

/“IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.”

Corporate or legal name of entity which owns the business and iles income tax returns: (see attached example)

Bank Name (print):

Branch:

Bank Street Address:

City:

State:

EFT Bank Route Transit Number:

EFT Bank Account Number:

Signature of Retailer, Owner or Principal:

Date:

Printed Name of Retailer, Owner or Principal:

THE SECTION BELOW MUST BE COMPLETED BY DEPOSITORY INSTITUTION (BANK)

7.DEPOSITORY INSTITUTION ACKNOWLEDGMENT: The above account has been established “IN TRUST FOR ThE GEORGIA LOTTERY CORPORATION.” We acknowledge that our customer, the Retailer, has directed us to provide information concerning the above referenced account to the Georgia Lottery Corporation upon request by an authorized representative of the Georgia Lottery Corporation. We further

acknowledge that the Retailer has directed us to provide this information in accordance with subsection (e)(2) of Section 502 of the “Gramm- Leach-Bliley Act of 1999” (15 U.S.C.A. § 6802), and we will continue to provide such information as directed until receipt of Retailer’s written

revocation in the manner set forth in Section 6 above.

Revised 3/12/13

PART 4 - Retailer Contract

Lottery Retailer ID:

ThIS RETAILER CONTRACT is between GEORGIA LOTTERY CORPORATION (GLC), a public corporation created pursuant to

the Georgia Lottery for Education Act (Act), and the undersigned Retailer. Capitalized terms used herein shall have the meanings

set forth in Appendix A to GLC's Retailer Rules and Regulations, unless otherwise deined in context. Subject to approval by GLC

of Retailer’s application to sell lottery Tickets, Retailer and GLC hereby agree as follows:

1.Retailer Rules. Retailer agrees to comply with and be bound by the Act, the Rules and Regulations of GLC, and all other applicable laws, rules, regulations, ordinances and orders. Retailer agrees at all times to meet the minimum qualiications for a GLC Retailer and to notify GLC of any changes in its business, as speciied in the Act and the Rules and Regulations. Copies of the Act and all

Rules and Regulations are always available upon request from GLC.

2.Term and Renewal, Unless earlier terminated, the term of this Retailer Contract shall begin as of the date it is executed by

Retailer, as shown below, shall remain in effect for a period of one (1) year, and may be renewable annually at the sole discretion of GLC. In the event that GLC and Retailer have entered into any Retailer Contract(s) dated prior to the date of this Retailer Contract, GLC and Retailer agree that from the beginning of the term hereof, this Retailer Contract shall amend, renew, replace, and restate any prior Retailer Contract in its entirety for each Retailer Business Location listed below.

3.Contract Termination. This Retailer Contract may be canceled by Retailer upon twenty (20) calendar days prior written notice to GLC. If the CEO determines, in her/his sole discretion, that cancellation, denial, revocation, suspension or termination of this Retailer

Contract is in the best interest of GLC, the State of Georgia or the public welfare, the CEO may cancel, deny, revoke, suspend or terminate this Retailer Contract upon written notice to Retailer; provided, however, Retailer shall be entitled to a hearing on such cancellation, denial, revocation, suspension or termination in accordance with the Act and the Rules and Regulations; provided, further,

that the CEO may temporarily suspend Retailer’s rights under this Retailer Contract without prior notice, pending any prosecution,

hearing or investigation, in accordance with the Act. In addition to the foregoing, GLC may immediately cancel, deny, revoke, suspend, terminate, or refuse to renew this Retailer Contract for any of the reasons set forth in Exhibit A on the next page hereof.

4.Ticket Sales, Retailer agrees to sell lottery Tickets for all the games authorized by GLC, in GLC‘s sole discretion, and only at its

Retailer Business Locations listed below for which GLC has issued a Certiicate of Authority under this Retailer Contract. Retailer agrees that it shall sell no other lottery Tickets in the State of Georgia, except those provided to it for sale by GLC. Retailer agrees

that it shall adopt safeguards to assure that it will not sell lottery Tickets or pay prizes to persons under the age of 18 years. Retailer agrees that it shall sell lottery Tickets only at the prices, and only subject to the terms and conditions, ixed by GLC unless prior written authorization is received from the CEO in each instance. In accordance with the amounts speciied in the Act and the Rules

and Regulations, as full and complete compensation under this Retailer Contract, GLC will pay Retailer Commissions and other compensation for lottery Tickets sold and for winning lottery Tickets paid by Retailer.

5.Electronic Funds Transfer. Retailer shall have a iduciary duty to preserve and account for all proceeds from the sale of lottery

Tickets collected by it and shall be responsible and liable for all such proceeds. All proceeds from the sale of lottery Tickets and all other funds due the GLC shall constitute a trust fund in favor of the GLC until paid to the GLC. Subject to the Act and the Rules

and Regulations, Retailer agrees. (i) to maintain for the purpose of this Retailer Contract a separate bank account in the name of the Retailer as "Trustee for the Georgia Lottery Corporation”, with a bank acceptable to GLC which is a member of an automated clearing house association; (ii) to deposit daily into that bank account all proceeds from the sale of lottery Tickets and other funds due the GLC; (iii) to authorize GLC to initiate Electronic Funds Transfer (EFT) to and from that account for the net settlement due from the sales of GLC lottery Tickets; and (iv) that suficient funds shall be available in the designated account on the dates speciied

by GLC to cover the amounts due GLC, as determined by GLC.

6.Prize Payments. During its normal business hours, Retailer agrees to immediately validate and pay all lottery Tickets winning prizes up to and including $600 for all lottery games that it is authorized by GLC to sell, in accordance with the Act and the Rules and Regulations. Such payment for winning Tickets shall not be in amounts greater or less than the amounts authorized by GLC, and shall never be subject to restrictions or conditions other than those imposed by GLC.

7.Promoting Sales. Retailer agrees to prominently display, in locations accessible to the public, point-of-sale advertising and other public information material and supplies provided from time to time by GLC and its Vendors and suppliers. Retailer agrees to attend all training sessions, as requested from time to time by GLC. In order to assist Retailer with sales of lottery Tickets, GLC and its

Vendors and suppliers may provide certain equipment (such as Lottery Terminals, Ticket dispensers, Ticket vending machines, play stations, etc.) to be held in the custody and control of Retailer without any transfer of ownership of such equipment to Retailer; Retailer agrees to return any such equipment and supplies upon request of the owner and agrees to be inancially liable and responsible for the use, preservation and protection of such equipment and supplies, normal wear and tear excepted.

8.Acceptance and Return of Instant Tickets, Subject to the conditions and reporting requirements more fully set forth in the

Rules and Regulations: (i) each Retailer shall have a iduciary duty and responsibility to preserve and account for all Instant Tickets accepted from the GLC or its distributor, as well as cash proceeds from the sale of any lottery products; (ii) any Instant Tickets not

properly accounted for by the Retailer upon termination of the Retailer Contract, upon demand by the GLC, or at the End of Game

date for the corresponding Instant Game, regardless of the reason, shall be deemed to have been purchased by the Retailer; (iii)

Retailer shall be responsible for the full price of Instant Tickets, less any applicable Commissions, for all Instant Tickets which may

be lost, stolen, or damaged after delivery to Retailer; and (iv) GLC will accept full and partial Instant Ticket Pack returns within (3)

weeks of the termination, cancellation, suspension, revocation or non-renewal of this Retailer Contract.

Page 1 of 2

Revised 3/12/13

Lottery Retailer ID:

9.Contract Changes. This Retailer Contract, including the Act and the Rules and Regulations, is the entire contract between GLC and

Retailer. This Retailer Contract may not be modiied or amended except by a writing signed by both parties hereto or by amendment to the Act or the Rules and Regulations. To the extent of any conlict, the provisions of the Act shall govern the Rules and Regulations, and the Rules and Regulations shall govern the Retailer Contract.

IN WITNESS WhEREOF, GLC and the undersigned Retailer have executed, or caused their duly authorized representatives to execute,

this Retailer Contract as of the date noted below.

1.Corporate or legal name (list the name of the legal entity which owns the business and iles income tax returns):

2.Store Name or d/b/a (List the name of the business where tickets are to be sold. If more than one Retailer Business Location, list all locations on the attached schedule I.):

3.Business Locations (Street, City, State & Zip of the location where tickets are to be sold):

4.Printed Name and Title:

5.By (signature):

6.Date:

GEORGIA LOTTERY CORPORATION

By:

Debbie D. Alford, President and CEO

EXHIBIT A to Retailer Contract

Notice of Speciic Reasons for which a Retailer Contract may be Terminated

GLC may immediately cancel, deny, revoke, suspend, terminate, or refuse to renew any Retailer Contract if a Retailer or any of its owners:

a.violates a provision of the Act or of the Rules and Regulations; or

b.is or has been, or retains an employee involved in the sale of lottery Tickets who is or has been, convicted of a criminal offense related to the security or integrity of GLC or a lottery in any other jurisdiction; or

c.is or has been, or retains an employee involved in the sale of lottery Tickets who is, or has been, convicted of a gambling‑related offense, false statements, false swearing or perjury in this or any other jurisdiction or a crime punishable by more than one year of imprisonment or a ine of more than $1,000.00 or both unless the person’s civil rights have been restored and at least ive (5) years have elapsed from the date of the completion of the sentence without a subsequent conviction of a crime described above; or

d.commits fraud, misrepresentation or deceit; or

e.provides false or misleading information to GLC; or

f.acts in a manner prejudicial to the security or integrity, or the public conidence in the security or integrity, of GLC; or

g.conducts business for the sole purpose of selling lottery Tickets; or

h.is delinquent in the payment of any federal, state or local taxes owed by it; or

i.changes any Retailer Business Location for which GLC has issued a Certiicate of Authority under this Retailer Contract; or

j.fails to accurately or timely account for proceeds or prizes from the sale of lottery Tickets; or

k.fails to accurately or timely account for lottery Tickets received from GLC; or

l.fails to comply with any term of this Retailer Contract; or

m.fails to maintain a minimum level of sales, as established by GLC from time to time; or

n.substantially changes the ownership of Retailer without prior written notice to, or consent of, GLC; or,

o.iles for or is placed in bankruptcy, receivership, insolvency or similar proceedings or fails to pay its debts as they become due; or

p.resides in the same household as any director, oficer or employee of GLC; or

q.contracts with any other person or entity for lottery goods or services without the prior written approval of GLC; or

r.fails to meet any of the objective criteria established by GLC pursuant to the Act, or

s.is subjected to any material change, as determined to be material in the sole discretion of GLC, in any matter considered by GLC in entering this Retailer Contract; or

t.fails to maintain the designated account from which Electronic Funds Transfers (EFT) payments are to be made, fails to authorize GLC to initiate EFT transactions to and from such designated account, or fails to have suficient funds available in such designated account on the dates speciied by GLC.

Page 2 of 2

Revised 3/12/13

Dear Bank Representative:

Thank you for assisting our Retailer applicant. The Retailer must establish a separate electronic funds transfer (EFT) bank account in order to complete their Georgia Lottery

Corporation application. This separate bank account must be speciied “In Trust For the Georgia Lottery Corporation.”

Example:

XYZ, Inc.

D/B/A RCA Food Mart

In Trust for the Georgia Lottery Corporation

Please ensure that the account is not titled “Lottery Account.”

If you need any additional information, or have any questions, please contact Retailer Contracts Administration at 1-800-746-8546 option 4.

Revised 3/12/13

GEORGIA LOTTERY CORPORATION

Helpful Hints for completing the GLC Retailer Application Package

In order to facilitate the eficient processing of your GLC Retailer Application,

we’ve itemized some helpful hints for you.

Also, be sure to carefully read the Retailer Application instructions.

1.When making corrections, please use a single line to cross through the incorrect information. Then initial your correction.

Do not use white out. Applications with white out cannot be accepted.

2.Please ensure that all information on the application is accurate and complete before submitting to the Georgia Lottery

Corporation. An incomplete or inaccurate application will only slow down the processing of your application.

3.Please maintain a copy of the application for your reference during the application process.

4.Identiication:

Please submit one of the following forms of valid identiication. No other forms of identiication can be accepted:

·Driver’s License

·Georgia Identiication Card

·Identiication Card issued by another state

·U.S. Armed Forces Identiication Card

·U. S. Passport

·U.S. Resident Alien Card

5.Application Fee:

·The Application fee should be in the form of a cashier’s check, business check, or money order only.

·No personal checks or counter checks can be accepted.

·Please do not submit the application fee with a check from the Lottery EFT account.

6.Business Registration/Tax ID #s (Part 3 of the application):

·Federal Employers ID number: Obtain from the IRS by calling 1-800-829-0115. If you are a sole proprietorship, please use only your Social Security Number.

·All Corporations and Limited Liability Corporations must be properly registered with the Secretary of State.

·Further information can be obtained by contacting the Corporations Division of the Secretary of State at 404-656-2817 or by visiting their website at http://www.sos.state.ga.us/corporations/iling_procedures.htm.

·All businesses must be registered with the Georgia Department of Revenue. Please call (404) 417-4490 to obtain registration information.

·Georgia State Tax Identiier Number & Georgia Sales Tax Number:

If already registered, this number can be found on your Georgia Department of Revenue registration certiicate.

7.Legal Business Name/Ownership Type:

·Corporate or Legal Name: The legal entity which owns the business and iles income tax returns.

·Store Name or DBA Name: The name of the business where tickets are sold. This name should match the Georgia Department of Revenue registration.

·Sole Proprietor: Your legally given name.

·Partnership: Partnership name should match the name on the Internal Revenue Service notiication of the Federal Employers Identiication Number.

·Corporation and Limited Liability Corporation: Please ensure that the legal business name and Secretary of

State registered name match.

Revised 3/12/13

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georgia lottery claim form printable spaces to consider

Enter the appropriate information in Signature, of, Owner, or, Principal Print, or, TypeName Title, Date, NOTARY, SEAL, HERE STATE, OF COUNTY, OF YEAR, Notary, Public, Sealand, Signature My, Commission, Expires Name, Title, Function, CellPhone Yes, No and Business, Hours, Open, Close part.

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stage 3 to finishing georgia lottery claim form printable

The Revised, Title, Race, Home, Street, Address Percent, of, Ownership, DateofBirth City, State, Zip, Code Home, Phone, Number CellPhone, Number, Social, Security, Number Email, Address Yes, and NoN, oN, oNo section will be the place to insert the rights and responsibilities of both sides.

georgia lottery claim form printable Revised, Title, Race, HomeStreetAddress, PercentofOwnershipDateofBirth, CityStateZipCode, HomePhoneNumber, CellPhoneNumberSocialSecurityNumber, EmailAddress, Yes, and NoNoNoNo fields to fill out

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Depository Institution Representative (print):

Telephone Number:

Signature of Depository Institution Representative: