The Georgia Lottery Application Form is a comprehensive document required for businesses seeking to become authorized retailers of lottery tickets in Georgia. It outlines specific requirements, including a non-refundable application fee, business information, personal information of owners and principals, and an agreement to participate in the Electronic Funds Transfer Authorization system for handling lottery funds. Detailed instructions guide applicants through each section, ensuring clarity in the submission process. To take the next step in becoming a Georgia Lottery Retailer, complete the application form by clicking the button below.
Exploring the Georgia Lottery Application form reveals a systematic process designed for businesses aiming to become authorized retailers of lottery tickets within the state. This comprehensive form mandates an initial fee, structured to partially refund applicants should their application not gain approval. It painstakingly gathers essential details about the business, including its legal name, operational addresses, contact information, and the specifics about each principal or owner involved. Importantly, Part 2 delves into personal information of these individuals, covering a breadth of questions aimed at ensuring the integrity and legality of the business and its operators. Additionally, a notable section prompts the disclosure of minority ownership statuses, reflecting an effort to recognize diversity in business ownership. The form also outlines requirements for establishing a trust account for electronic funds transfers, ensuring a secure pathway for the financial transactions associated with lottery sales. Completing the form, Part 4 outlines the contract agreement between retailers and the Georgia Lottery Corporation, cementing the obligations and expectations from both parties. This document serves not only as an application but as a foundational guide for prospective retailers, ensuring they understand the responsibilities and regulations accompanying the sale of lottery tickets.
GEORGIA LOTTERY CORPORATION
Instructions for Retailer Application Packet 1-800-746-8546 - OPTION #4 & then #7 - Retailer Contracts Administration
Revised 4/1/18
PART 1 - Business Information
PART 2 - Personal Information (Owner)
A Georgia Lottery Retailer application 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.)
This form must be completed for each owner, shareholder, member, and officer of the business. Make additional copies if necessary.
Lines 1 - 14 - List all information requested.
Line 1 - List the name of the entity which owns the business and files 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 - COAM information - Complete all information requested for Coin Operated Amusement Machines.
Line 18 - 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 defined 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”; or
•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 19 - Business Hours - List business hours for Sunday through Saturday.
LOTTERY OFFICIAL TO COMPLETE ALL SHADED ENTRIES
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 identification (Driver's License, Georgia Identification Card, Identification Card issued by another state, U.S. Armed Forces Identification 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
Lines 2 - 4 - Obtain and list required licensing numbers from the Georgia Department of Revenue (State Tax Identifier, 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 verifies 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 - E-Verify Affidavit
The completed/executed affidavit is required of ALL GLC Retailer
Applicants. See the E-Verify Affidavit Instructions Letter for
important information regarding the completion of this affidavit.
PART 5 - 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
Restaurant/Truck Stop
Auto Supply
Convenience
Home Improvement
Not Classified
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
Retailer Application
P.O. Box 56486 • Atlanta, GA 30343 1-800-746-8546 - OPTION #4 & then #7 - Retailer Contracts Administration
Please submit completed application with $125 fee per business location
(Cashier’s Check, Business Check, or Money Order only).
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PLEASE PRINT
Lottery Retailer ID#:
1.Corporate or legal name (List the name of the legal entity which owns the business and files 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 officer of the Business (for example, sole proprietors, general partners, corporate officers, 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.
c.
d.
15.Applicant certifies 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 certifies 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 qualification 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, confidential 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:
SEAL
SWORN TO AND SUBSCRIBED BEFORE ME ON THIS
DAY OF
(MONTH)
(YEAR)
Notary Public Seal and Signature:
My Commission Expires:
HERE
Personal Identification (ID) is required to be presented to and verified by Notary Public. Type of ID:
ID Number:
16. Business Contacts (Persons Authorized to Conduct On-Site Lottery Transactions):
Name
Title/Function
Cell Phone #
17. Is this business location licensed for Coin Operated Amusement Machines (COAM)? ___Yes
___No
If Yes, provide the following:
# of Class A Machines:_________
# of Class B Machines:_________
COAM Location License #_________________________
COAM Master License # __________________________
18. (OPTIONAL) Is Business Ownership more than 50% of a minority race?
Yes
No
If yes, Specify: African American
Native American
Asian
Hispanic
Other (specify):
19. Business Hours:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Open
Close
To be completed by Lottery Representative
Business Trade Style: (see Instruction Sheet)
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Make additional
P.O. Box 56486 • Atlanta, GA 30343
copies if necessary.
1-800-746-8546 - OPTION
#4 & then #7 - Retailer Contracts Administration
This form must be completed for each owner, shareholder, member, and officer of the business.
1. Type of Ownership:
Sole Proprietor Partnership
Corporation
Non-Profit
LLC (Corporation) LLC (Partnership)
Other(specify):
2.
First, Middle & Last Name of Owner or Principal (no initials):
M or F:
4. Place of Birth:
Title:
6.
Race:
7. Percent of Ownership:
8. Date of Birth:
9.
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 officer or
employee of the Georgia Lottery Corporation?
•Are you a vendor, employee or agent of any vendor of the Georgia Lottery Corporation?
•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?
•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 fine of more than $1,000.00 or both ? If yes, where?
and when?
•Are you delinquent in taxes, fees or other obligations owed to the State of Georgia?
•Have you filed bankruptcy in the last seven (7) years?
•Are you related to a COAM Class B Master Licensee?
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 Certificate 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 identification for each owner. The following is a list of acceptable forms of identification: Driver's License, Georgia Identification Card, Identification Card issued by another state, U.S. Armed Forces Identification 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 qualification 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 official 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 qualifications. 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, confidential 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 final termination of my Retailer’s contractual obligations with the GLC.
Signature
Print Name
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.
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1-800-746-8546 - OPTION #4 then #7 - Retailer Contracts Administration
PART 3 - Lottery Retailer Electronic Funds Transfer Authorization
1. Corporate or Legal Name (list the name of the legal entity which owns the business and files income tax returns):
2. Georgia State Tax Identifier 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 file 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 specified “IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.” The Retailer’s depository institution must confirm 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 files income tax returns: (see attached example)
Bank Name (print):
Branch:
Bank Street Address:
State:
EFT Bank Route Transit Number:
EFT Bank Account Number:
Signature of Owner or Principal:
Date:
Printed Name of 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.
Depository Institution Representative (print):
Telephone Number:
Signature of Depository Institution Representative:
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Part 4 – Lottery Retailer E-Verify Affidavit
The GLC Retailer, signed below, confirms and verifies its compliance with Georgia law (See OCGA §13-10-91, as amended), and affirmatively states that the business (Sole Proprietor, Partnership, Corporation, Non-Profit, LLC Corporation, or LLC Partnership) which sells GLC lottery tickets: (check and complete #1 or #2 below)
Legal Business Name of Georgia Lottery Retailer/Applicant:
____1. Has registered with, is authorized to use, and uses the federal work authorization program commonly
known as E-Verify, or any subsequent replacement program. Furthermore, the undersigned retailer will continue to use the federal work authorization program throughout the contract period. Retailer hereby attests that its federal work authorization user identification number and date of authorization are as follows:
_______________________________________________
Federal Work Authorization User Identification Number
This number is at least 4 or more digits in length, does not contain letters and is NOT your Federal Employer Identification Number (FEIN).
Date of Authorization
OR
____2. Employs no employees, or otherwise does not fall within the requirements of OCGA §13-10-91.
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on _______________ DAY OF __________, 20 in _________________(city) _____________(state).
_________________________________________________________
Signature of Authorized Owner/Officer
____________________________________________________
Printed Name and Title of Authorized Owner/Officer
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF __________, 20___.
____________________________________________________________
NOTARY PUBLIC
My Commission Expires: ______________________________________
Important E-Verify Affidavit Instructions
Dear Valued GLC Lottery Retailer Applicant:
The Georgia Security and Immigration Compliance Act (OCGA §13-10-91) has been amended by the passage of Georgia Senate Bill 160, which implemented new retailer contract requirements for the Georgia Lottery Corporation (“GLC”).
As a result, all new GLC Retailers contracted after July 1, 2013 must submit an E-Verify affidavit to the GLC with their GLC Retailer application. The E-Verify affidavit provides proof of the retailer’s registration and participation in E-Verify, the current federal work authorization program.
Under the amended law, a new GLC retailer must submit an E-Verify affidavit with an E-Verify user number (Federal Work Authorization User Identification Number), unless the business has no employees (in which case it must present an approved state-issued identification card or driver's license, with an E-Verify affidavit that it has no employees).
The E-Verify Affidavit is attached:
a)Complete Section 1 of this affidavit to provide the GLC an E-Verify user number. If you are not currently registered in the E-Verify program and do not have an E-Verify number, one can be obtained on-line, for free, at http://www.dhs.gov/e-verify. For further information, visit the website or contact the U. S. Department of Homeland Security at 888-464-4218.
b)Your E-Verify number is at least 4 or more digits in length, does not contain letters and is NOT your
Federal Employer Identification Number (FEIN).
c)If your business has NO employees, place a check mark in section 2 and ensure a copy of an approved state-issued identification card or driver's license is provided with E-Verify affidavit.
d)Once an E-Verify user number is obtained for Section 1 or a copy of the state-issued identification card or driver’s license is obtained for Section 2, the business owner (or authorized representative of the business) on the original GLC contract must sign the affidavit, before a notary.
e)The notarized affidavit must be returned to the GLC with your completed GLC Retailer Application package.
If you have any questions, please contact your GLC Sales Representative, or the RCA (Retailer Contracts Administration) department at 1-800-746-8546 - option #4 then #7.
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 defined 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 qualifications for a GLC Retailer and to notify GLC of any changes in its business, as specified 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 Certificate 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, fixed by GLC unless prior written authorization is received from the CEO in each instance. In accordance with the amounts specified 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 fiduciary 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 sufficient funds shall be available in the designated account on the dates specified 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 financially 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 fiduciary 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
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 modified 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 conflict, 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 files income tax returns):
2.Business Address where tickets are to be sold:
(Street)
(City, State & Zip)
3. Printed Name and Title:
By:
4. By (signature):
5. Date:
Gretchen Corbin, President and CEO
EXHIBIT A to Retailer Contract
Notice of Specific 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 fine of more than $1,000.00 or both unless the person’s civil rights have been restored and at least five (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 confidence 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 Certificate 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.files 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, officer 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 sufficient funds available in such designated account on the dates specified by GLC.
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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 specified “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 then #7.
Helpful Hints for completing the GLC Retailer Application Package
In order to facilitate the efficient 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.Identification:
Please submit one of the following forms of valid identification. No other forms of identification can be accepted:
·Driver’s License
·Georgia Identification Card
·Identification Card issued by another state
·U.S. Armed Forces Identification Card
·U.S. Passport (must be signed)
·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.ga.gov/index.php/corporations.
·All businesses must be registered with the Georgia Department of Revenue. Please call (404) 417-4445 to obtain registration information.
·Georgia State Tax Identifier Number & Georgia Sales Tax Number:
If already registered, this number can be found on your Georgia Department of Revenue registration certificate.
7.Legal Business Name/Ownership Type:
·Corporate or Legal Name: The legal entity which owns the business and files 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 notification of the Federal Employers Identification Number.
·Corporation and Limited Liability Corporation: Please ensure that the legal business name and Secretary of
State registered name match.
Filling out the Georgia Lottery Application form is a straightforward process that opens the door to becoming an authorized lottery retailer in the state. This opportunity not only expands your business offerings but also attracts more customers to your location. Before starting, ensure you have all the necessary information about your business, including legal documentation, tax identification numbers, and personal information for each principal of the business. Follow these steps carefully to ensure that your application is complete and accurate.
Ensure that all information provided is accurate and truthful. Inaccuracies or omissions can lead to rejection or future complications with your application. Once submitted, the Georgia Lottery Corporation will review your application for approval. This process includes background checks and financial evaluations to ensure compliance with Georgia Lottery regulations and standards. Being thorough and precise in your application is the best way to ensure a smooth approval process.
What is the application fee to become a Georgia Lottery Retailer, and is it refundable?
The application fee to become a Georgia Lottery Retailer is $125 for each business location. If the application for a business location is not approved, $100 of this fee will be refunded.
What information is required from the business in the Georgia Lottery Retailer Application?
The application requires the legal or corporate name of the entity owning the business, the store name or DBA (doing business as), business location including the address and phone number, mailing address if different, fax number if applicable, and detailed information for each principal of the business. Additionally, business contacts and operating hours must be listed.
Is there a section in the application concerning minority business ownership?
Yes, there is an optional section on the form for indicating if more than 50% of the business is owned by individuals of a minority race. Although filling this section is not mandatory, it helps in identifying the business as minority-owned based on the definitions provided in Georgia statutes.
What personal information is required from each owner or principal in the application process?
Part 2 of the application requires each owner, shareholder, member, and officer to provide detailed personal information, including type of ownership, full name, gender, place of birth, title, race, percentage of ownership, and date of birth. Additional details such as home address, phone numbers, social security number, email address, and questions about criminal history and financial status are also needed. Identification verification with a notarized statement is necessary as well.
How does the Electronic Funds Transfer Authorization part of the application work?
The application requires setting up a separate bank account for electronic funds transfers (EFT) “In Trust for the Georgia Lottery Corporation”. Retailers must authorize the Georgia Lottery Corporation to initiate debit and credit entries to this account and must have the depository institution acknowledge the establishment of this trust account.
What is the purpose of the Retailer Contract included in the Georgia Lottery Retailer application package?
The Retailer Contract outlines the terms and conditions under which the retailer agrees to operate, including compliance with laws and regulations, term and renewal details, sales expectations, electronic funds transfers, prize payments, and the promotion of sales. It also specifies requirements for the acceptance and return of instant tickets.
What happens if the business ownership changes after submitting the Georgia Lottery Retailer application?
If there are any changes in business ownership or other significant business details after submitting the application, the retailer is obligated to notify the Georgia Lottery Corporation immediately. Such changes may require additional review or alterations to the existing application or contractual agreement.
Filling out the Georgia Lottery Retailer Application requires attention to detail and an understanding of the application process. A common mistake is not including the required payment of $125 per business location with the application. This fee is crucial for the processing of the application, and omitting it can delay or invalidate the entire application process. Applicants must remember to submit this fee in the form of a cashier’s check, business check, or money order to ensure their application is considered.
Another frequent oversight is the failure to list the legal name of the entity that owns the business in line 1 of the application. This detail is key because it identifies the applicant in legal terms and distinguishes it from any 'doing business as' (d/b/a) names listed later. Ensuring the legal name is accurately and completely provided is fundamental for the application’s legitimacy and future communications.
Moreover, applicants often neglect to provide a separate mailing address when it differs from the business address. This misstep, seen in lines 9 to 12, can lead to important correspondence from the Georgia Lottery Corporation being misrouted or delayed, potentially affecting vital aspects of lottery retailer operations.
One of the components easily overlooked is the requirement in line 15 for the statement to be notarized. The importance of this process is to officially verify the signer's identity and their acknowledgment of the application's contents. Skipping this step can result in an incomplete application, delaying the approval process.
Line 17, while optional, is another area where mistakes are made. Applicants who qualify under the minority business ownership criteria but fail to indicate this status miss a valuable opportunity to have their business recognized under this classification. This acknowledgment could lead to additional support or resources being made available to them.
In Part 2 of the application, a common error lies in not attaching a copy of the required form of identification for each individual listed. This oversight in line 22 can halt the verification process, a critical step to ensure that all principals of the business meet the legal requirements for lottery retail operation.
Last but not least, Part 3's Electronic Funds Transfer (EFT) Authorization, specifically lines 6 and 7, is often inaccurately completed. Retailers must authorize the Georgia Lottery Corporation to initiate debit and credit entries accurately and ensure the bank acknowledges the account is held “In Trust for the Georgia Lottery Corporation.” Any inaccuracies or omissions in this section could lead to financial transactions being delayed or incorrectly processed, impacting the retailer’s ability to conduct lottery sales efficiently.
When applying to become a Georgia Lottery Retailer, the main application form is just the beginning. Various other forms and documents play vital roles in ensuring compliance, security, and proper financial management alongside the application process. Understanding these documents will streamline the application process, ensuring that all the necessary steps are taken for a successful submission.
Each of these documents contributes to the comprehensive review process conducted by the Georgia Lottery Corporation. By thoroughly preparing and submitting each required piece, applicants significantly increase their chance of becoming authorized retailers. It's crucial for applicants to gather, accurately fill, and submit these forms and documents in a timely manner to ensure their application is considered without unnecessary delays.
The Georgia Lottery Application form shares similarities with a Business License Application typically used by state or local government agencies. Both documents require detailed information about the business, including legal names, ownership structure, and contact information. They are designed to assess eligibility and compliance with specific regulatory requirements, emphasizing the need for accuracy and truthfulness. The licensing process for both involves reviewing the qualifications of the business and its principals to ensure they meet established criteria before granting approval.
Similarly, it mirrors a Bank Account Opening form, which also requires comprehensive identification and business information, including federal and state tax identification numbers and details about the business’s legal structure. Like the lottery application, opening a bank account necessitates providing personal information for each significant owner and agreeing to financial transactions—such as electronic funds transfers—highlighting the necessity for trust and accountability in handling financial operations.
A Vendor Application form for participation in events or markets also bears resemblance to the lottery application. Both forms collect business and personal information to evaluate the applicant's suitability and ensure they meet specific criteria. These documents often request details on the nature of the business and its owners, similar to how the lottery application requires disclosures about the business’s operations, ownership, and even minority status, aiming at a comprehensive understanding of the business’s background and operational context.
The application shares traits with a Liquor License Application too. Both types of applications are regulatory in nature, requiring detailed information about the business premises, ownership, and operational details. Important elements like business hours, ownership structure, and compliance with state laws are crucial in both forms to ensure lawful operation. Liquor and lottery licenses both necessitate thorough reviews by the issuing authorities to confirm compliance with specific state regulations, focusing on the applicant's integrity and the establishment's suitability for conducting sensitive activities.
Last, the Georgia Lottery Application form resembles a Credit Application for a commercial account due to its in-depth financial scrutiny. Applicants must provide financial information and authorize credit checks and other investigations to evaluate their financial responsibility and stability. This process ensures that entities involved have the capacity to manage credit or, in the case of the lottery, the flow of funds associated with lottery sales. Both forms act as vetting tools to assess the risk and ensure financial integrity within a business arrangement.
When filling out the Georgia Lottery Application form, it's important to follow certain guidelines to ensure the application process is smooth and successful. Here are four things you should do and four things you shouldn't do.
There are several common misconceptions about the Georgia Lottery Application form process that are important to clarify:
Understanding these points can help simplify the application process for prospective Georgia Lottery Retailers, ensuring that businesses of all types can consider adding lottery sales to their service offerings with accurate expectations.
When applying to become a Georgia Lottery retailer, a non-refundable fee of $125 per business location is required, with $100 refundable if the application is not approved.
The application necessitates thorough business information, including the legal name of the entity, the storefront or business name, and contact details.
Each principal, owner, shareholder, or officer of the business must complete a separate section of the application, requiring detailed personal information and a notarized statement.
Applicants must disclose any criminal history, including offenses that could impact the integrity of the lottery operations, and provide specifics if any form of bankruptcy has been filed within the last seven years.
For the Electronic Funds Transfer Authorization portion, the business must have a separate bank account in trust for the Georgia Lottery Corporation, ensuring daily deposits of lottery sales proceeds.
Identification for each individual involved must be attached, choosing from a list of acceptable forms, including driver's licenses and passports.
Minority business ownership identification is encouraged but not mandatory, aiming to promote diversity among Georgia Lottery retailers.
Business hours, including days of operation, must be listed, ensuring availability for lottery sales throughout the week.
A signed retailer contract is necessary for each member of a partnership or LLC, underlining the terms of operation, including sales compliance, prize payment responsibilities, and promotional requirements.
The application also has sections that expect the applicant to authorize the Georgia Lottery Corporation to conduct thorough background checks, including credit reports and criminal history, to assess the applicant’s eligibility.
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