Michigan Lottery Retailer Forms Details

For Michigan lottery form information, the lottery commission provides an online application. The application is simple to fill out and submit. In addition to providing your personal information, you must also declare how much money you would like to spend on tickets each week. If you win a prize greater than $600, the state will withhold 25% of your winnings for federal taxes. Note that these taxes are in addition to the 6% Michigan state tax withheld from all prizes won in the state. Finally, if you'd like to remain anonymous after winning a prize, the state allows you to do so at no cost.

Here, you may find quite a few details about michigan lottery form PDF. Prior to complete the form, it is worth checking more about it.

QuestionAnswer
Form NameMichigan Lottery Form
Form Length23 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min 45 sec
Other namesmichigan lottery license application, michigan lottery form 5754, lottery retailer application, michigan lottery claim form

Form Preview Example

RETAILER

APPLICATION

Rev. 08/15

MICHIGAN LOTTERY

RETAILER SERVICES

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

MICHIGAN LOTTERY RETAILER - APPLICANT REQUIREMENTS -

The requirements listed below pertain to Retailers interested in selling Michigan Bureau of State Lottery (Lottery) products. Failure to meet any of these requirements, the terms and conditions of the contract or any other provision of the Lottery Act and Rules may result in disciplinary action up to and including license revocation depending on the nature and severity of the violation.

1.The Lottery advises all applicants for licenses and/or changes of ownership not to invest any money or commit themselves by any binding agreements in the expectation of being issued a license or approval of a change of ownership until officially notifi ed by the Lottery that their application has been approved.

2.Most applicants with an acceptable credit history and no criminal record that would adversely affect the integrity of the Lottery may be licensed. Lottery may require a bond from a Retailer as a condition

of licensure. ANY CRIMINAL RECORD MUST BE DISCLOSED ON PERSONAL DATA SHEETS.

3.The items listed in the applicant checklist are required before the Lottery will license the location.

4.A nonrefundable application fee of $150 is due at time of application. This fee may be remitted by check payable to the State of Michigan or paid on-line at https://www.thepayplace.com/mi/lottery/retailerserv

5.Retailers are required to maintain a separate account in a fi nancial institution that is a member

of The National Automated Clearing House Association. The Lottery must be authorized to initiate electronic funds transfers (EFT) to or from the Retailer’s designated account for the net weekly settlements due from the sale of instant and/or on-line game tickets. The Retailer shall ensure that “good” funds shall be available in the designated account to cover said transfers on the day of week specifi ed by the Lottery.

“Good” funds are defined as unrestricted funds credited to a Retailer’s account that a financial institution will release for payment of an EFT. Unrestricted funds do not include checks placed on hold until they have cleared the maker’s account or deposited checks that the maker’s fi nancial institution has returned unpaid. Any cash alternative settlement methods (such as line of credit, overdraft protection, a pre-approved loan, or any other arrangements) agreed upon with your bank are the Retailer’s responsibility. If a settlement is not honored by your bank, regardless of the reason, the Lottery will consider it a delinquency.

Applicants should submit a completed Electronic Funds Transfer (EFT) Authorization Form with the application. If this EFT account will not be established until closing of the sale, a void check or a letter, on bank letterhead, with the bank’s routing number and your checking account number may

be submitted at that time. Lottery products will not be made available to the Retailer until this information is provided.

6.Annual license renewal fee is $200. This fee will be waived for those Retailers who are not on probation for violation of the Lottery Act or its Rules at the time of renewal.

7.It is recommended the Retailer provide (prior to the installation of Lottery equipment) a dedicated circuit with 115 volts, 20 Amp. 60 HZ service with an isolated ground that remains on 24 hours per day. The dedicated circuit must have a 4 outlet box that will accommodate 3 prong, “U” grounded type plugs. The Lottery reserves the right to require a Retailer to obtain certifi cation of a dedicated electrical circuit from a qualifi ed electrician. All installation and ongoing costs for this service will be the responsibility of the Retailer. The outlet shall be located within fi ve feet of the terminal. The Retailer shall provide suffi cient space for the operation of the equipment.

-OVER -

Authority: Act 239, 1972 as amended.

BSL-S-685A(2/16)

8.BUSINESS TYPE - to determine your business type use these defi nitions when completing the application. A Personal Data Sheet and signature is required before the application will be processed.

a.PROPRIETORSHIP - a business enterprise doing business under an assumed name, that is owned by one person (not registered with the Michigan Department of Labor & Economic Growth). A Proprietorship may use the owner’s Social Security number as a tax identification number or s/he may have a registered Federal Employer Identifi cation Number (FEIN). The owner must complete and sign the contract and submit a Personal Data Sheet.

b.PARTNERSHIP - a business enterprise doing business under an assumed name that is NOT registered as a Partnership with the Michigan Department of Labor & Economic Growth. Each Partner must sign the contract and Personal Data Sheets must be provided for all partners.

c.LIMITED PARTNERSHIP - a business enterprise, doing business under an assumed name, that IS registered as a Partnership with the Michigan Department of Labor & Economic Growth. A General Partner must sign the contract and Personal Data Sheets must be provided for all general partners.

d.LIMITED LIABILITY COMPANY - a business enterprise, doing business under an assumed name, that is registered as an unincorporated association with the Michigan Department of Labor & Economic Growth. Members are required to sign the contract and submit Personal Data Sheets. (Members are defi ned as persons having ownership interest in a limited liability company.)

e.CORPORATION - a business enterprise organized as a corporate entity, doing business under an assumed name, that is registered with the Michigan Department of Labor & Economic Growth.

“Closely Held Corporation” means a corporation where a majority (more than 50 percent) of the outstanding voting stock is owned by ten or fewer persons. Any person authorized and empowered to execute contracts and bind the corporation to its terms and obligations may sign the contract. A Personal Data Sheet is required for each owner/shareholder, except that any individual owning less than 10 percent may be listed on a separate sheet of paper and is required only to provide name, Social Security number and percent of ownership.

“Non-Closely Held Corporation” means a corporation where a majority (more than 50 percent) of the outstanding voting stock is owned by more than ten persons. The Principal Operating

Offi cer(s) is/are required to sign the application and submit Personal Data Sheet(s). (A Principal Operating Offi cer is defi ned as a person designated to conduct business in the State of Michigan on behalf of the corporation being licensed.)

f.To properly comply with the reporting requirements for the Internal Revenue Service, the Lottery must change the Retailer number assigned to you when you change your business structure. The Lottery defi nes a change in business structure as anytime your Taxpayer Identification Number, Corporate Number or business type (sole proprietor, partnership or corporation) changes.

When your Retailer number is changed, we must fi nancially close out the old Retailer number. This will result in all activated books having to be settled and paid for, regardless of the length of

time they have been activated or the percentage of validations that have occurred within each book. Once a book has been activated we are unable to reassign the book, which is why payment is required.

You will then be assigned a new Retailer number and all confi rmed books will be reassigned to this new number.

9.Please note that the accompanying Retailer license application requires that you indicate if your business is in compliance with the Americans with Disabilities Act (ADA). If you have any questions about compliance, please contact the State ADA Coordinator, at 517-373-3125.

If you have any questions, call RETAILER SERVICES (517) 335-5619.

Send completed documents to: Michigan Lottery

Attn: Retailer Services

P.O. Box 30023

Lansing, MI 48909

MICHIGAN LOTTERY

RETAILER SERVICES

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

MICHIGAN LOTTERY RETAILER - GENERAL REQUIREMENTS -

1.A person must be 18 years of age or older to buy or sell Lottery tickets.

2.Retailers must display their Lottery license or a copy of their Lottery license in a conspicuous place.

3.Retailers may sell tickets only on the premises indicated on the license. Only instant tickets issued to a specifi c location can be sold at that location. Retailers may not exchange books of instant tickets with other Retailers or stores.

4.All Retailers are expected to redeem winning tickets with a value up to and including $600. Winning tickets must be validated through the validation system(s) for the Retailer to receive credit.

5.Write your Retailer number on the back of all winning tickets that you redeem and deface the validation number. Destroy redeemed tickets after balancing.

6.Retailers are expected to make full use of all promotional material provided by the Lottery and to prominently post winning numbers/symbols and jackpot amounts as soon as possible.

7.Retailers are expected to participate in Lottery signage programs and to display approved sign(s) provided by the Lottery.

8.Retailers are required to offer for sale instant tickets.

9.Lottery tickets cannot be sold for more than their established price. They can be sold for less than their established price as a special promotion if the Retailer desires. Retailers who sell tickets to other Retailers for resale are in violation of the Lottery Act & Rules.

10.Retailers cannot offer to give any money or other thing of value to the holder of a Lottery ticket

or share for winning the Lottery, other than the prize if payment of the prize by the Retailer is authorized by the Commissioner. Retailers who offer bonuses to Lottery winning tickets holders are in violation of the Lottery Act & Rules.

11.Retailers cannot purchase a winning ticket or tickets from an original purchaser or from a subsequent purchaser.

12.Retailers are prohibited from participating as a Retailer for other Lotteries.

13.The sale of a valid Lottery ticket is fi nal and a Retailer shall not accept ticket returns.

14.Lottery may prohibit a person authorized by the Retailer from participating in a Lottery activity i.e. selling tickets or redeeming tickets.

15.A Retailer, upon issuance of a license, will receive 6% commission on each ticket sold and a 2% commission on any prize paid. Retailers may also receive bonus commissions as stated in Lottery directives. For more information on bonus commissions visit the Lottery website.

16.Retailers are expected to maintain current and accurate records of all operations in conjunction with sales in conformity with Rules, instructions, and directives of the Lottery. The Retailer is required to make the records available to Lottery representatives upon request.

-OVER -

Authority: Act 239, 1972 as amended.

BSL-S-685B(03/13)

17.The Retailer shall exercise due diligence in the operation of any installed equipment and shall immediately call 1-800-592-4040 and press option #1 when his or her equipment malfunctions. The Retailer shall refrain from attempting to perform any mechanical or electrical maintenance or repairs to the equipment except as instructed by Lottery or its authorized representative. If terminal malfunction is a result of Retailer noncompliance with Lottery guidelines or specifi cations, the Retailer may be responsible for repair and/or service charges. The Retailer shall replace ribbons, paper stock, and clear paper jams as required.

18.A Retailer does not have a property interest in the license granted by the Lottery or in the online Lottery terminal.

19.The Retailer will act in a fi duciary capacity with respect to all tickets accepted from Lottery or its authorized distributors until payment has been made.

20.Retailers are responsible for all tickets consigned to them. If tickets are stolen, then the Retailer shall report the theft to the Lottery and to local or state police authorities. The Retailer shall pay for the stolen tickets on the settlement date. The Retailer shall subsequently fi le a statement swearing to or

affi rming, under the penalty of perjury, the facts of the case. The Retailer shall furnish to Lottery a copy of the police report covering the theft. Following an investigation by Lottery and police authorities, Lottery may issue a refund to the Retailer. Refunds may only be issued if losses to Lottery have been mitigated by Retailer’s actions in reporting the tickets stolen and the Retailer’s appropriate accounting of tickets stolen.

21.The Retailer shall be responsible for the physical security of the Lottery equipment. Damage to the equipment/satellite communication lines attributable to the Retailer’s negligence will result in an assessment to the Retailer for the cost of equipment repair or replacement.

22.Retailers agree to hold Lottery and the State of Michigan harmless from any liability arising in connection with the sales or redemption of Lottery products.

23.If you plan to sell your business and the buyer wants to continue Lottery sales, a change of ownership must be approved by the Lottery. The buyer should submit an application approximately 45 days prior to closing. Contact Retailer Services for details (517) 335-5619.

MICHIGAN LOTTERY

RETAILER SERVICES

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

MICHIGAN LOTTERY RETAILER

- WEEKLY SETTLEMENT REQUIREMENTS -

1.Retailers must not be delinquent in settling accounts with the Lottery.

2.Retailers are required to maintain a separate bank account for Lottery use only in a fi nancial institution that is a member of The National Automated Clearing House Association. The Lottery must be authorized to initiate electronic funds transfers (EFT) to or from the account.

3.Cash only must be deposited in this account, do not include checks in your deposit.

4.The sales week is Tuesday through Monday. Your invoice is available Tuesday of each week. Bank deposits must be made by 2:00 p.m. on Tuesday to assure available funds for EFT withdrawal.

5.A Retailer’s selling privileges may be suspended upon determination that the Retailer is delinquent for any settlement. Retailers are considered delinquent when sufficient good, available funds are

not available in the financial institution account at the time the Lottery attempts to electronically withdraw the Retailer’s settlement.

6.Retailers are expected to promptly “make good” a delinquency by remitting a cashier’s or certified check to the Lottery for the full amount of the delinquency plus any delinquency fee. A fee may be assessed for each delinquency in accordance with the fee schedule currently in effect.

7.A Retailer who fails to “make good” a delinquency shall be subject to license revocation. A retailer may also be subject to collection proceedings for failure to “make good” on a deliquency. Collection proceedings may be initiated by the Lottery or by a designated third-party.

8.A Retailer who exceeds the established number of delinquencies within six consecutive months shall be subject to license revocation or be required to post a cash bond to continue as a licensed Retailer.

Authority: Act 239, 1972 as amended.

BSL-S-685D(05/15)

MICHIGAN LOTTERY

RETAILER SERVICES

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

MICHIGAN LOTTERY RETAILER

- PERFORMANCE REQUIREMENTS -

1.The Retailer shall immediately notify Retailer Services of any lapse in on-line terminal operation that will exceed 48 hours in duration.

2.The Retailer’s license may be revoked if the Retailer has an unapproved lapse in operation that exceeds 30 calendar days.

3.Under Lottery Rules, the Retailer must pay the fees established by Lottery. These fees include the following:

a.Application Processing Fee - $150 A nonrefundable application fee is due at the time of application.

b.Investigation Fee - $700 This fee may be assessed to the Retailer when an investigation is conducted resulting in disciplinary action.

c.Satellite Communication Equipment Installation Fee - $550 This fee is for the installation of communication service for an on-line Lottery terminal.

d.Delinquency Fee - $200 This fee may be assessed by the Lottery each time a Retailer is delinquent.

e.Annual License Renewal Fee - $200 This fee will be waived for those Retailers who are not on probation for violation of the Lottery Act or its Rules at the time of renewal.

f.Low Sales Fee - $70 Retailers may be subject to a fee if they do not meet the terminal minimum sales performance amount of $500 a week.

4.Retailers will be given written notice when fees are changed by Lottery.

5.All Retailers may be subject to a terminal minimum sales performance evaluation every quarter. Failure to meet the minimum sales performance may result in license revocation. The minimum

sales performance amount is set by the Lottery and is subject to change, but will not exceed a $4,000.00 weekly average.

6.Failure to meet the performance requirements or the contract terms and conditions may result in disciplinary action depending on the nature and severity of the violation. When the severity of a violation warrants equipment removal and/or license revocation, the Retailer may request a conference with the Commissioner or the Commissioner’s designee. At this informal conference, the alleged violation will be reviewed with the Retailer. The Retailer will have the opportunity to refute the alleged violation or to explain the reasons for the violation. The Retailer will be notifi ed in writing of the Commissioner’s decision. The Commissioner’s decision is final.

7.It is each owner/shareholder’s responsibility to report to the Lottery any changes in his or her personal or business situation that would adversely affect Lottery’s integrity and/or its operations. This includes but is not limited to: any change of ownership, changes in a home address, phone number, etc; misdemeanor or felony convictions; liquor, food stamp, or tobacco violations; tax defaults or liens; personal or business bankruptcies; or any pending lawsuits against an owner/shareholder

or the business.

8. Each owner/shareholder authorizes the release of all information regarding his or her personal/business credit and criminal history to the Lottery. Each owner/shareholder understands it is his or her responsibility to report any changes in a personal or business situation. Each owner/shareholder accepts that any violation of the Lottery Act, Rules, contract, directives, instructions, or communications (including this communication) may be cause for revocation of any Lottery license.

To report any changes, contact Lottery at: Michigan Lottery, Retailer Services, P.O. Box 30023,

Lansing, MI 48909; or by fax at (517) 241-0645; or by emailing MSL-RetailerServices@michigan.gov; or by calling (517) 335-5619.

Authority: Act 239, 1972 as amended.

BSL-S-685C(08/15)

MICHIGAN LOTTERY

RETAILER SERVICES

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

MICHIGAN LOTTERY RETAILER

- OPERATIONAL RULES -

PULL TAB GAMES



The following business types are eligible to sell Pull-Tabs: bar/restaurant, restaurant, bowling center, golf & golf club, social club, adult entertainment, kiosk and racetrack.

Retailers are prohibited from selling Pull Tab tickets for a price other than the price printed on the ticket.

Pull Tab tickets may be sold from vending machines specifi cally designed to dispense Pull Tab tickets, by waitstaff, from “fi shbowl” type containers, or through special promotional packaging provided by the Lottery. The cost to purchase or lease the vending machine(s) is the responsibility of the Retailer unless the game is sold in special promotional packaging provided by the Lottery.

Retailers receive a 6% commission on each Pull Tab ticket sold and a 2% commission on any prize paid, unless otherwise stated in the Lottery contract.

Retailers are prohibited from selling Pull Tab tickets to a visibly intoxicated person.

Retailers may not end sales of a game until all tickets from the deal are sold or unless a game has expired.

Retailers may redeem winning tickets of $600 or less. Prizes of $601 and above must be claimed at a Lottery claim center or Lottery office.

Retailers must pay the full amount of all prizes redeemed from valid winning Pull Tab tickets.

A winning prize must be claimed prior to the expiration date listed on the Pull Tab ticket.

Retailers may not manipulate the Pull Tab game in order to prevent prizes from being awarded.

Retailer employees and owners may purchase, play and redeem Pull Tab tickets.

Authority: Act 239, 1972 as amended.

BSL-S-1893(9/15)

MICHIGAN LOTTERY

RETAILER SERVICES

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909 www.michiganlottery.com

NONPROFIT LICENSEES ONLY

- REQUIREMENTS -

The requirements listed below pertain to the licensing of nonprofit organizations.

PRINCIPAL OFFICERS

The Retailer Contract/Application must be signed by the three principal offi cers (i.e. president, vice president, treasurer, secretary) of the organization.

Each of the principal offi cers must complete and sign a Personal Data Sheet authorizing the Lottery to perform a personal criminal and credit check.

The Lottery reserves the right to deny or revoke a license based on the criminal and/or credit history of any principal officer.

Lottery references to owners/ownership means any and all of the principal officers and/or Lottery chairpersons.

Principal offi cers must be at least 18 years old.

Any change in principal offi cers must be reported to the Lottery by completing a new Retailer Contract/ Application and Personal Data Sheet.

LOTTERY CHAIRPERSON

Each location must designate a Lottery chairperson who will be the Lottery contact and responsible for all Lottery activities. This includes making the Lottery deposits on Tuesday before 2:00 p.m., stocking supplies, and other necessary activities.

The Lottery chairperson, if different from the principal officers, must sign the Retailer Contract/Application. He/she must also complete and sign a Personal Data Sheet authorizing the Lottery to perform a personal criminal and credit check.

The Lottery reserves the right to deny or revoke a license based on the criminal and/or credit history of the Lottery chairperson.

The designated Lottery chairperson must be indicated on the Retailer Contract/Application.

The Lottery chairperson must be at least 18 years old.

Any change in the Lottery chairperson must be reported to the Lottery by completing a new Retailer Contract/Application and Personal Data Sheet.

BYLAWS/CONSTITUTION

A copy of the organization’s bylaws or constitution must be provided unless the organization is currently licensed by the Michigan Lottery’s Charitable Gaming Division.

All organizations licensed by Charitable Gaming must provide their organization’s ID number on the Retailer Contract/Application.

OWNERSHIP OF BUILDING

A copy of the lease, deed, rental agreement or other proof must be provided to show the organization’s legal right to occupy the building/premises.

LOTTERY ACT & RULES

The principal offi cers and Lottery chairperson, by signing the Retailer Contract/Application and Personal Data Sheet, agree to comply with the Lottery Act and Rules, or the requirements, instructions and directives of the Commissioner or Bureau.

The organization must comply with any Michigan Liquor Control Commission Rules or statutes. Specifi cally, organizations must adhere to prohibitions that no alcohol is sold to anyone who is not a bona fi de member or guest of the club (as defi ned by statute).

Authority: Act 239, 1972 as amended.

BSL-S-2044(5/13)

MICHIGAN LOTTERY

RETAILER SERVICES

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

RETAILER CONTRACT / APPLICATION

A nonrefundable application fee of $150 is due at the time of application. This fee shall be remitted by check payable to the State of Michigan, or paid on-line at https//wwww.thepayplace.com/mi/lottery/retailerserv

Submission of application and fee does not guarantee equipment placement.

LOTTERY USE ONLY

APPL. #

 

RET. #

 

 

 

 

 

CITY

COUNTY

CHAIN

 

 

 

 

Business / Organization Name

 

 

 

 

Number and Street

 

 

 

 

 

 

City

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code

 

 

 

Phone Number

 

 

 

Fax Number

 

Date Business Was

Current Lottery Retailer Number of

 

 

 

 

(

)

 

 

 

 

(

)

 

 

 

 

Purchased by You

This Location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(if applicable)

 

 

IS THIS LOCATION IN COMPLIANCE WITH THE REQUIREMENTS OF THE AMERICANS WITH DISABILITIES ACT?

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS IF DIFFERENT FROM BUSINESS ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

Street Address or P.O. Box

 

 

 

 

 

City

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATURE OF APPLICATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New License

 

 

 

Change of Ownership

Add Partner

 

 

 

Drop Partner

Stock Transfer

 

Change in Business Type

 

Change in Offi cers/Chairperson

Other ____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDICATE BUSINESS TYPE (Refer to Applicant Information Sheet):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sole Proprietorship

 

 

Limited Partnership

 

 

Limited Liability Company

 

 

 

 

FED ID # (FEIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Partnership

 

 

Corporation

 

 

Non-Profit Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALL BUSINESSES OTHER THAN SOLE PROPRIETORSHIP MUST PROVIDE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legal Entity Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Headquarters Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK THE BOX SHOWING YOUR PRINCIPAL BUSINESS:

 

 

 

 

Kiosk

 

 

 

 

 

 

 

 

Fraternal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supermarket

 

 

 

Liquor/Party Store

 

 

 

 

Seasonal Account

 

Religious

 

 

 

Convenience Store

 

 

 

Mass Merchandiser

Bowling

 

 

 

 

 

 

 

 

Service

 

 

 

 

Gas/Convenience Store

 

Mass Grocery Merchandiser

Golf

 

 

 

 

 

 

 

 

Veteran

 

 

 

 

Restaurant

 

 

 

Drug Store

 

 

 

 

Race Track

 

 

 

 

 

 

 

 

Social Club - Private

 

Bar/Restaurant

 

 

 

Recreation

 

 

 

 

Adult Entertainment

 

Golf Course - Private

 

Bar

 

 

 

Specialty Shop

 

 

 

 

Other (Explain) _______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WRITE THE APPLICABLE MICHIGAN LIQUOR CONTROL LICENSE(S) NUMBER ISSUED TO THE APPLICANT FOR THIS BUSINESS, AT THIS

LOCATION. (If pending receipt, write pending):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Liquor License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOES YOUR ESTABLISHMENT HAVE CUSTOMER SEATING WITH 5 OR MORE TABLES?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-PROFIT ORGANIZATIONS MUST COMPLETE THIS SECTION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Charitable

 

 

 

 

 

 

Name of State

 

 

 

 

 

 

 

Approximate #

 

 

 

 

Gaming

 

 

 

 

 

 

or National

 

 

 

 

 

 

 

 

 

 

 

Organization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of members

 

 

 

 

 

 

 

 

 

 

 

Affliation

 

 

 

 

 

 

 

 

 

 

 

 

 

ID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTER THE HOURS OF OPERATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sunday

 

Monday

 

 

Tuesday

Wednesday

 

Thursday

 

 

Friday

 

Saturday

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Open

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Close

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS CONTRACT between the Michigan Bureau of State Lottery, hereinafter referred to as the “Lottery”, and

________________________________________________, dba ____________________________________________________,

INDIVIDUAL(S) / CORPORATION / ORGANIZATION

DBA (Doing Business As)

hereinafter referred to as the “Retailer”, shall take effect on the day the Lottery license is issued and shall continue until terminated by written notice by either party or until a mutually agreed date of termination.

-OVER-

 

COMPLETION: Required.

 

 

PENALTY: Denial of application.

 

 

Authority: Act 239 of the Public Acts of 1972, as amended.

BSL-S-953(03/15)

THE PARTIES agree as follows:

1.The Retailer agrees to provide services for the Lottery for the sale of products authorized by the Lottery in conformity with Act No. 239 of the Public Acts of 1972, as amended. The Retailer agrees to abide by all Lottery Rules, directives, performance requirements and offi cial written communications issued by the Lottery.

2.The Retailer agrees to abide by all federal, state, and local laws, rules, and regulations.

3.The Retailer shall maintain current and accurate records of all operations in conjunction with sales in conformity with rules, instructions, and directives of Lottery. The Retailer shall make the records available to representatives of Lottery upon request for inspection and audit.

4.The Retailer’s Lottery license and the rights and obligations established by this Contract are NOT assignable or transferable. The Lottery reserves the right to disapprove or qualify approval of an application for a change of ownership. The Lottery reserves the right to remove any Lottery equipment if the change of ownership is not approved by the Lottery.

5.The Retailer shall obtain written Lottery approval prior to any change of location of the Retailer’s business premises (e.g., the Retailer moves from one business location/address to another location/address). For any change in business location the Retailer shall pay any and all costs associated with the relocation (e.g., communication system connections, equipment connections, etc.).

6.The Retailer shall provide written notice to the Lottery of any proposed sale, dissolution or termination of the Retailer’s business and/or any change in ownership of the Retailer’s business. All changes are subject to the Lottery’s approval and may be denied if:

a.The proposed new owner does not satisfy the Lottery’s requirements for past compliance, integrity, financial responsibility, or any other criteria for initial licensure;

b.The Retailer has not settled all outstanding accounts with the Lottery.

7.The Lottery shall pay the Retailer the prevailing commission rate for all valid sales and for all valid prize payments.

8.The Lottery or its designated representative shall provide equipment, routine maintenance, and supplies related to the operation of the installed equipment to the Retailer at no cost, except as may be assessed for installation, repair or replacement, failure to meet performance requirements, or failure to surrender equipment upon notice by the Lottery or its designated representative.

9.The equipment provided by Lottery or its designated representative shall be used at all times for its intended purpose and not altered in any way. If the Retailer intentionally or negligently uses, alters, or fails to maintain the equipment, the Retailer may be subject to disciplinary action, including but not limited to, paying costs for repair, maintenance, or replacement of the equipment.

10.The Retailer understands that prompt and timely remittance to Lottery of all funds due is essential. One possible consequence of failing to make prompt and timely remittance to Lottery may be the initiation of collection proceedings by Lottery or a designated third-party.

11.Each of the undersigned persons represents and warrants that s/he has reviewed and fully understands the Contract and that:

a.S/he is a person authorized to execute this Contract and bind the Retailer to its terms and obligations.

b.S/he, individually and together, and for her or his personal estate, guarantees to the Lottery the Retailer’s faithful performance of the Contract. Without limiting the generality of the foregoing guarantee and merely by way of example, this includes:

1)safe custody and prompt return to the Lottery or its designated representative, when required, of any equipment, tickets, materials and supplies owned and/or to be owned by the Lottery.

2)prompt and timely remittance to the Lottery of all funds due.

c.TERMINATION OF THE CONTRACT BY EITHER PARTY SHALL NOT EXTINGUISH ANY OBLIGATION WHICH AROSE WHILE THIS CONTRACT WAS IN EFFECT.

Each owner/shareholder/principal offi cer/Lottery chairperson signs below (add sheet, if needed).

TYPE OR PRINT NAME OF INDIVIDUAL

SIGNATURE

DATE

 

 

 

 

TYPE OR PRINT TITLE

PERCENT OF STOCK

 

 

 

 

 

 

 

 

 

 

TYPE OR PRINT NAME OF INDIVIDUAL

SIGNATURE

DATE

 

 

 

TYPE OR PRINT TITLE

PERCENT OF STOCK

 

 

 

 

 

 

 

 

 

 

TYPE OR PRINT NAME OF INDIVIDUAL

SIGNATURE

DATE

 

 

 

TYPE OR PRINT TITLE

PERCENT OF STOCK

 

 

 

 

 

 

 

 

 

 

TYPE OR PRINT NAME OF INDIVIDUAL

SIGNATURE

DATE

 

 

 

TYPE OR PRINT TITLE

PERCENT OF STOCK

 

 

 

 

 

 

 

 

 

 

TYPE OR PRINT NAME OF INDIVIDUAL

SIGNATURE

DATE

 

 

 

TYPE OR PRINT TITLE

PERCENT OF STOCK

 

 

 

 

 

 

 

 

 

 

A Personal Data Sheet is required for person(s) signing above and additional owner(s)/shareholders as described on the Applicant Information sheet.

ENTER THE NUMBER OF PERSONAL DATA SHEETS SUBMITTED ________.

MICHIGAN LOTTERY

LICENSING SECTION

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

PERSONAL DATA SHEET

Business Name (dba) _________________________________________________________________________________

EACH OWNER, PARTNER, PRINCIPAL SHAREHOLDER, CORPORATE OFFICER, PRINCIPAL OFFICERS, AND/OR LOTTERY CHAIRPERSONS OF THIS BUSINESS/ORGANIZATION MUST COMPLETE AND SIGN A PERSONAL DATA SHEET. (USE AS MANY ADDITIONAL SHEETS AS NECESSARY.)

NAME (LAST, FIRST, M.I.)

 

 

 

 

MAIDEN NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NO. *

 

DATE OF BIRTH

 

 

SEX

DRIVER’S LICENSE NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME ADDRESS (NO., STREET)

 

 

CITY

 

STATE

ZIP

COUNTY

 

 

 

 

 

 

 

 

 

HOME PHONE NUMBER

CELL PHONE NUMBER

 

EMAIL ADDRESS

 

TITLE

 

 

% OWNERSHIP

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* PROTECTED BY FEDERAL PRIVACY LAWS AND STATE CONFIDENTIALITY REQUIREMENT

1.Full name of spouse ______________________________________________________________________________

2.I or my spouse previously held, or now hold interest in the following licenses for sale of Lottery products as sole licensee, partner or corporation: (attach additional sheets if necessary)

RETAILER NUMBER

STORE NAME

 

 

ADDRESS

YESNO

3. If you are not a U.S. citizen - are you a registered alien?

YESNO

4. Have you ever legally changed your name?

YESNO

or do you have a Visa?

From ___________________________________________ to ____________________________________________

YESNO

5. Have you ever been known by any other names?

Give names ____________________________________________________________________________________

Questions 7 - 13 relate to criminal offenses, either felony or misdemeanor. Answer each question as it pertains to you. DO NOT include civil traffic violations.

6. Have you ever:

YES NO

YES NO

been arrested or detained

pled no contest

been indicted or charged

forfeited bail

pleaded guilty

been convicted

If you answered yes to any of the above, complete the following table:

NATURE OF OFFENSE

DATE OF CHARGE

OR INCIDENT

M/D/YYYY

NAME AND ADDRESS OF COURT OR

POLICE AGENCY

DISPOSITION

DATE

M/D/YYYY

FELONY (F)

OR

MISDEMEANOR (M)

Yes No

7. Have you ever been granted immunity?

Yes No

8. Have you ever been named an un-indicted co-conspirator?

- OVER -

COMPLETION: Required.

PENALTY: Denial of application.

Authority: Act 239 of the Public Acts of 1972, as amended.

BSL-S-1479(5/15)

9.Have you ever been charged with a criminal offense, either felony or misdemeanor, which did not result in a conviction?

Yes No If you answered yes, describe the nature and date of the charge, name of government agency, and disposition.

10. Have you ever been placed on a diversionary program to avoid criminal arrest or conviction?

Yes No If you answered yes, describe the circumstances, outcome, and efforts being made to pay back any debt incurred.

11.Describe any arrests, which did not result in formal criminal charge.

Not Applicable

12.Has this business/organization or have you individually ever been investigated or penalized by a state or federal agency?

Yes No If yes, attach explanation that includes the date, location, charge, disposition, and the government agency involved.

13. Has this business/organization or have you individually ever failed to pay taxes, fees, or other obligations owed to the U.S. government, a state government, or any local governmental subdivisions?

Yes No

If yes, attach explanation that includes the date of default, type of tax or fee in default and date cleared.

14. Have you ever had any involvement in a personal or business bankruptcy or business in receivership?

Yes No

If yes, attach explanation.

15. Are there currently any lawsuits pending against you or your business/organization?

Yes No

If yes, attach reason for suit, plaintiff, amount(s) of uninsured potential damages.

WARNING: Rule 432.4 provides that the Retailer’s license may be immediately suspended or revoked or its renewal rejected if the application for license contains false or misleading information.

I HAVE EXAMINED THIS INFORMATION AND VERIFY IT IS COMPLETE AND CONTAINS NO MISREPRESENTATIONS OR FALSE STATEMENTS. I AUTHORIZE THE RELEASE OF ALL INFORMATION REGARDING MY PERSONAL/BUSINESS CREDIT AND CRIMINAL HISTORY TO THE MICHIGAN LOTTERY. I UNDERSTAND IT IS MY RESPONSIBILITY TO REPORT ANY CHANGES IN THE ABOVE INFORMATION. I ACCEPT THAT ANY VIOLATION OF THE LOTTERY ACT, RULES, CONTRACT, DIRECTIVES, INSTRUCTIONS, OR COMMUNICATIONS MAY BE CAUSE FOR REVOCATION OF ANY LOTTERY LICENSE.

SIGNATURE

DATE

MICHIGAN LOTTERY

LICENSING SECTION

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

PERSONAL DATA SHEET

Business Name (dba) _________________________________________________________________________________

EACH OWNER, PARTNER, PRINCIPAL SHAREHOLDER, CORPORATE OFFICER, PRINCIPAL OFFICERS, AND/OR LOTTERY CHAIRPERSONS OF THIS BUSINESS/ORGANIZATION MUST COMPLETE AND SIGN A PERSONAL DATA SHEET. (USE AS MANY ADDITIONAL SHEETS AS NECESSARY.)

NAME (LAST, FIRST, M.I.)

 

 

 

 

MAIDEN NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NO. *

 

DATE OF BIRTH

 

 

SEX

DRIVER’S LICENSE NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME ADDRESS (NO., STREET)

 

 

CITY

 

STATE

ZIP

COUNTY

 

 

 

 

 

 

 

 

 

HOME PHONE NUMBER

CELL PHONE NUMBER

 

EMAIL ADDRESS

 

TITLE

 

 

% OWNERSHIP

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* PROTECTED BY FEDERAL PRIVACY LAWS AND STATE CONFIDENTIALITY REQUIREMENT

1.Full name of spouse ______________________________________________________________________________

2.I or my spouse previously held, or now hold interest in the following licenses for sale of Lottery products as sole licensee, partner or corporation: (attach additional sheets if necessary)

RETAILER NUMBER

STORE NAME

 

 

ADDRESS

YESNO

3. If you are not a U.S. citizen - are you a registered alien?

YESNO

4. Have you ever legally changed your name?

YESNO

or do you have a Visa?

From ___________________________________________ to ____________________________________________

YESNO

5. Have you ever been known by any other names?

Give names ____________________________________________________________________________________

Questions 7 - 13 relate to criminal offenses, either felony or misdemeanor. Answer each question as it pertains to you. DO NOT include civil traffic violations.

6. Have you ever:

YES NO

YES NO

been arrested or detained

pled no contest

been indicted or charged

forfeited bail

pleaded guilty

been convicted

If you answered yes to any of the above, complete the following table:

NATURE OF OFFENSE

DATE OF CHARGE

OR INCIDENT

M/D/YYYY

NAME AND ADDRESS OF COURT OR

POLICE AGENCY

DISPOSITION

DATE

M/D/YYYY

FELONY (F)

OR

MISDEMEANOR (M)

Yes No

7. Have you ever been granted immunity?

Yes No

8. Have you ever been named an un-indicted co-conspirator?

- OVER -

COMPLETION: Required.

PENALTY: Denial of application.

Authority: Act 239 of the Public Acts of 1972, as amended.

BSL-S-1479(5/15)

9.Have you ever been charged with a criminal offense, either felony or misdemeanor, which did not result in a conviction?

Yes No If you answered yes, describe the nature and date of the charge, name of government agency, and disposition.

10. Have you ever been placed on a diversionary program to avoid criminal arrest or conviction?

Yes No If you answered yes, describe the circumstances, outcome, and efforts being made to pay back any debt incurred.

11.Describe any arrests, which did not result in formal criminal charge.

Not Applicable

12.Has this business/organization or have you individually ever been investigated or penalized by a state or federal agency?

Yes No If yes, attach explanation that includes the date, location, charge, disposition, and the government agency involved.

13. Has this business/organization or have you individually ever failed to pay taxes, fees, or other obligations owed to the U.S. government, a state government, or any local governmental subdivisions?

Yes No

If yes, attach explanation that includes the date of default, type of tax or fee in default and date cleared.

14. Have you ever had any involvement in a personal or business bankruptcy or business in receivership?

Yes No

If yes, attach explanation.

15. Are there currently any lawsuits pending against you or your business/organization?

Yes No

If yes, attach reason for suit, plaintiff, amount(s) of uninsured potential damages.

WARNING: Rule 432.4 provides that the Retailer’s license may be immediately suspended or revoked or its renewal rejected if the application for license contains false or misleading information.

I HAVE EXAMINED THIS INFORMATION AND VERIFY IT IS COMPLETE AND CONTAINS NO MISREPRESENTATIONS OR FALSE STATEMENTS. I AUTHORIZE THE RELEASE OF ALL INFORMATION REGARDING MY PERSONAL/BUSINESS CREDIT AND CRIMINAL HISTORY TO THE MICHIGAN LOTTERY. I UNDERSTAND IT IS MY RESPONSIBILITY TO REPORT ANY CHANGES IN THE ABOVE INFORMATION. I ACCEPT THAT ANY VIOLATION OF THE LOTTERY ACT, RULES, CONTRACT, DIRECTIVES, INSTRUCTIONS, OR COMMUNICATIONS MAY BE CAUSE FOR REVOCATION OF ANY LOTTERY LICENSE.

SIGNATURE

DATE

Form W-9

(Rev. December 2014)

Department of the Treasury

Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Print or type See Specific Instructions on page 2.

1Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2Business name/disregarded entity name, if different from above

3

Check appropriate box for federal tax classification; check only one of the following seven boxes:

 

 

 

4 Exemptions (codes apply only to

 

Individual/sole proprietor or

C Corporation

S Corporation

Partnership

Trust/estate

certain entities, not individuals; see

 

instructions on page 3):

 

single-member LLC

 

 

 

 

 

 

 

 

 

 

 

 

 

Exempt payee code (if any)

 

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

 

 

 

 

 

Exemption from FATCA reporting

 

 

 

 

 

 

 

 

 

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for

 

 

 

 

 

the tax classification of the single-member owner.

 

 

 

 

 

code (if any)

 

Other (see instructions)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Applies to accounts maintained outside the U.S.)

 

 

 

 

 

 

 

 

5

Address (number, street, and apt. or suite no.)

 

 

Requester’s name and address (optional)

 

 

 

 

 

 

 

 

 

 

 

6

City, state, and ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

 

 

 

 

 

 

or

Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

1.The number shown 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 not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject 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 subject to backup withholding; and

3.I am a U.S. citizen or other U.S. person (defined below); and

4.The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of

 

U.S. person

Date

General Instructions

Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

Form 1099-INT (interest earned or paid)

Form 1099-DIV (dividends, including those from stocks or mutual funds)

Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

Form 1099-S (proceeds from real estate transactions)

Form 1099-K (merchant card and third party network transactions)

Form 1099-C (canceled debt)

Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1.Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2.Certify that you are not subject to backup withholding, or

3.Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4.Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X

Form W-9 (Rev. 12-2014)

Form W-9 (Rev. 12-2014)

Page 2

 

 

Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

An individual who is a U.S. citizen or U.S. resident alien;

A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;

An estate (other than a foreign estate); or

A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States:

In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1.The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2.The treaty article addressing the income.

3.The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4.The type and amount of income that qualifies for the exemption from tax.

5.Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup Withholding

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1.You do not furnish your TIN to the requester,

2.You do not certify your TIN when required (see the Part II instructions on page 3 for details),

3.The IRS tells the requester that you furnished an incorrect TIN,

4.The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5.You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9.

a.Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note. ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b.Sole proprietor or single-member LLC. Enter your individual name as

shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c.Partnership, LLC that is not a single-member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d.Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e.Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Form W-9 (Rev. 12-2014)

Page 3

 

 

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3.

Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the “Limited Liability Company” box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the “Limited Liability Company” box and in the space provided enter “C” for C corporation or “S” for S corporation. If it is a single-member LLC that is a disregarded entity, do not check the “Limited Liability Company” box; instead check the first box in line 3 “Individual/sole proprietor or single-member LLC.”

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code.

Generally, individuals (including sole proprietors) are not exempt from backup withholding.

Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.

Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a) 11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . .

THEN the payment is exempt for . . .

 

 

Interest and dividend payments

All exempt payees except

 

for 7

 

 

Broker transactions

Exempt payees 1 through 4 and 6

 

through 11 and all C corporations. S

 

corporations must not enter an exempt

 

payee code because they are exempt

 

only for sales of noncovered securities

 

acquired prior to 2012.

 

 

Barter exchange transactions and

Exempt payees 1 through 4

patronage dividends

 

 

 

Payments over $600 required to be

Generally, exempt payees

reported and direct sales over $5,0001

1 through 52

 

 

Payments made in settlement of

Exempt payees 1 through 4

payment card or third party network

 

transactions

 

 

 

1See Form 1099-MISC, Miscellaneous Income, and its instructions.

2However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940

I—A common trust fund as defined in section 584(a) J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1) M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5

Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns.

Line 6

Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on this page), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.

Form W-9 (Rev. 12-2014)

Page 4

 

 

Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, or 5 below indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

1.Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2.Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts 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 correct TIN to the requester, you must 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.

4.Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5.Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the Requester

 

For this type of account:

Give name and SSN of:

 

 

 

1.

Individual

The individual

2.

Two or more individuals (joint

The actual owner of the account or,

 

account)

if combined funds, the first

 

 

individual on the account1

3.

Custodian account of a minor

The minor2

 

(Uniform Gift to Minors Act)

 

4. a. The usual revocable savings

The grantor-trustee1

 

trust (grantor is also trustee)

 

 

b. So-called trust account that is

1

 

not a legal or valid trust under

The actual owner

 

 

 

state law

 

5.

Sole proprietorship or disregarded

The owner3

 

entity owned by an individual

 

6.

Grantor trust filing under Optional

The grantor*

 

Form 1099 Filing Method 1 (see

 

 

Regulations section 1.671-4(b)(2)(i)

 

 

(A))

 

 

 

 

 

For this type of account:

Give name and EIN of:

 

 

 

7.

Disregarded entity not owned by an

The owner

 

individual

 

8.

A valid trust, estate, or pension trust

Legal entity4

9.

Corporation or LLC electing

The corporation

 

corporate status on Form 8832 or

 

 

Form 2553

 

10.

Association, club, religious,

The organization

 

charitable, educational, or other tax-

 

 

exempt organization

 

11.

Partnership or multi-member LLC

The partnership

12.

A broker or registered nominee

The broker or nominee

13.

Account with the Department of

The public entity

 

Agriculture in the name of a public

 

 

entity (such as a state or local

 

 

government, school district, or

 

 

prison) that receives agricultural

 

 

program payments

 

14.

Grantor trust filing under the Form

The trust

 

1041 Filing Method or the Optional

 

 

Form 1099 Filing Method 2 (see

 

 

Regulations section 1.671-4(b)(2)(i)

 

 

(B))

 

1List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2Circle the minor’s name and furnish the minor’s SSN.

3You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account

title.) Also see Special rules for partnerships on page 2. *Note. Grantor also must provide a Form W-9 to trustee of trust.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records from Identity Theft

Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

Protect your SSN,

Ensure your employer is protecting your SSN, and

Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.

Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: spam@uce.gov or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.

MICHIGAN LOTTERY

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION

EFFECTIVE DATE

Retailer #

I authorize the Michigan Lottery to make variable withdrawals or deposits from or into the checking account identified below, and authorize the financial institution to charge such withdrawals or deposits to my listed checking account. The amount of the withdrawals or deposits will be equal to the amount shown on my invoice for gaming transactions. Adjusting entries are also authorized.

It is agreed that these withdrawals, deposits and adjustments may be made electronically and under the rules of the National Automated Clearing House Association. I understand that this authorization will remain in effect until a termination or change of checking account is confirmed by the Michigan Lottery.

Please note that you are ineligible to pay by ACH if the bank account identified on the void check/letter from the bank (on bank letterhead) is funded or otherwise associated with a foreign bank account to the extent that the payment transaction would qualify as an International ACH Transaction (IAT) under the NACHA Rules.

PLEASE ATTACH VOID CHECK OR A LETTER FROM THE BANK, ON BANK LETTERHEAD, WITH THE BANK'S ROUTING NUMBER AND YOUR CHECKING ACCOUNT NUMBER TO THIS AUTHORIZATION

Contact Person

Contact Person's Telephone Number

Store or Owner Fax #

 

(

)

 

 

(

)

 

 

 

 

 

 

 

Business Name as Shown on Lottery License (Please Print)

Signature of Authorizing Party (Owner, Partner, Other)

 

 

Date

 

 

 

 

 

 

 

 

Address: Street, P.O. Box

 

 

City

 

State

 

Zip Code

 

 

 

 

 

 

 

Bank Name

 

 

Bank Telephone Number

 

 

 

 

 

 

(

)

 

 

Checking (02)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MUST BE RECEIVED BY 3:00 P.M. MONDAY TO BE EFFECTIVE FOR TUESDAY

SETTLEMENT.

COMPLETION: Mandatory.

PENALTY: Loss of license.

This form is issued under the authority of Act 238, 1972 as amended.

BSL-A-667A(R2/16)

MICHIGAN LOTTERY MARKETING DIVISION P.O. BOX 30023 LANSING, MI 48909

COMMUNICATIONS EQUIPMENT INSTALLATION APPROVAL

Retailer #

Location

Michigan Lottery Retailer Landlord:

Please complete this form.

Please initial each of the following comments to indicate your acceptance of terms:

______ I will allow access to the roof for IGT installation technicians.

______ I understand that cable will be used to connect the wireless equipment on the roof

to the lottery terminal in the store.

Landlord Signature

Date

Landlord Contact

Phone

Comment for issues or special requests:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

COMPLETION: Required.

PENALTY: Denial of application.

Authority: Act 239, 1972 as amended.

BSL-M-2101(08/15)

TICKET CHECKER

Height: 12.5"

Width: 8.7"

Depth: 4.9"

TERMINAL

Height: 15.47"

Width: 13375"

CUSTOMER DISPLAY UNIT

Height: 15.3"

Width: 14.9"

Depth: 3.0"

Satellite Dish

Diameter. .74 m

Rftop .J'

30 ft. Data Cord

~ ..

X

~'"

!;:(

~

8

S!

.n

A

...J

~

Depth 18.95"

INDOOR UNIT

Height:11.5"

Width: 11"

Depth: 1.8"

PRINTER

Height: 7.59"

Width

6.5"

 

Depth

10.81"

 

 

II

II

6ft. Power Cord

 

 

COMPONENTS

.

 

 

II

II

 

 

 

Altura Terminal· 1 Outlet

 

Ticket Checker - 1 Outlet

 

CDU - 1 Outlet

 

 

 

Printer - Plugs Into Terminal

 

Indoor Unit -1 Outlet

 

~~

BSL-BSLS-2152(03/13)-A-08)

LOTTERY

MICHIGAN LOTTERY

RETAILER SERVICES

101 E. HILLSDALE, BOX 30023 LANSING, MICHIGAN 48909

www.michiganlottery.com

MICHIGAN LOTTERY

APPLICANT CHECKLIST

Your completed application must contain the following (an incomplete application can result in delay):

Retailer Contract/Application

Liquor Control License Number

Personal Data Sheet (one data sheet for each owner/shareholder)

Bill of Sale or Proof of Ownership (property tax statement, lease,

rental, or land contract, etc.)

EFT Authorization Form (include a void check or a letter, on bank letterhead, with the bank’s routing number and your checking account number)

Identification (out of state applicants must provide a photocopy of their driver’s license, social security card, and one other piece of identification)

Copy of IRS Notice CP 575A (Notice sent to you by IRS showing your Employer Identifi cation Number. If you are unable to locate this notice please contact IRS at 1-800-829-0115 and request a 147C letter be faxed or mailed to you to fulfi ll this requirement.) This requirement excludes sole proprietorships.

W-9 Form

$150 Nonrefundable Application Fee check made payable to State

of Michigan or pay on-line at https://www.thepayplace.com/mi/lottery/retailerserv

Communications Equipment Installation Approval Sheet

Make sure all forms are signed and dated. A nonrefundable application fee of $150.00 is due at the time of application. A communication equipment installation fee of $550 will be withdrawn from your account after the equipment is installed.

All forms and information can be mailed to the Lottery’s Retailer Services at the following address:

Michigan Lottery

Attn: Retailer Services

P.O. Box 30023

Lansing, MI 48909

OR:

Faxed if payment is paid on-line to (517) 241-0645.

Thank you for your interest in the Michigan Lottery.

Retailer Services (517) 335-5619

MSL-RetailerServices@michigan.gov

Authority: Act 239, 1972 as amended.

BSL-S-1856(2/16)