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LOTTERY RETAILER LICENSE RENEWAL APPLICATION NORTH DAKOTA OFFICE OF ATTORNEY GENERAL LOTTERY DIVISION SFN 54150 (07-2019) Answer the following questions: (Please type or print) Limited Liability Company NOTE: If LLC, how are taxes filed? Partnership Check one S-Corporation or C-Corporation Single Member Partnership C-Corporation S-Corporation Sole Proprietorship Federal Tax Classification (check one) Yes No Since October 1, 2018, has the retailer been bankrupt or in receivership? (If yes, explain on a separate sheet.) Yes No Since October 1, 2018, has a general manager, sole proprietor, partner, shareholder of a corporation (who owns 10% or more of the stock), a director, or an officer been convicted of a felony? (If yes, explain on a separate sheet.) Yes No Does the retailer owe delinquent taxes, interest, or penalties to the State of North Dakota? Yes No Is the retailer in full compliance with accessibility requirements of Title III of the Americans with Disabilities Act (ADA)? If no, please identify. Yes No Since October 1, 2018, has the retailer changed ownership or name? (If yes, explain on a separate sheet.) Taxpayer Identification Number (TIN) ND Sales Tax Permit Number List sole proprietor, partners, shareholders (who own 10% or more of the stock), directors or officers who are responsible for financial decisions, and onsite managers and/or general managers who oversee day to day operations of the lottery. Name Title Name Title I certify that I am the owner or person authorized to reapply to the North Dakota Lottery for a license and to enter into an agreement to be a retailer for the sale of lottery tickets. I certify that the information I have provided is true and complete. I understand that a false or misleading statement or a material omission of information on this application is cause for denial of this application or suspension/revocation of the retailer license. I authorize the Office of Attorney General to investigate criminal history, financial and credit information, delinquent taxes, and all other matters relating to the accuracy of any information provided on or attached to this application, including applications of related chain stores. I authorize the North Dakota Office of State Tax Commissioner to disclose confidential tax information on file to the Office of Attorney General for processing of this application. Print Full Name Date Signature of Owner or Authorized Person Title Email Address Legal Business Name (do not abbreviate) DBA Business Name (if different than legal name) Telephone Number If yes, is there a pending formal dispute or appeal relating to delinquent taxes, interest, or penalties owed to the State of North Dakota? If yes please explain. Note: The $150 Lottery license renewal fee will be collected through an Electronic Funds Transfer on September 17, 2019. Return by: August 23, 2019 Return to: Office of Attorney General, Lottery Division, 1050 E Interstate Ave. Suite 200 - Bismarck ND 58503-5574 Questions: Call the North Dakota Lottery at (701) 328-1574 or toll free at (877) 635-6886.
