retailer application

Rev. 8/3/2010 1 of 2

APPLICATION INSTRUCTIONS Please read the following instructions carefully before completing the forms in this application package.

SPECIAL NOTE: CHAIN STORES

Applications from chain outlets should be submitted through the chain central office, not by the individual store. If your business is part of a chain, check with your central office before completing this form. If your business is part of a chain that is applying for a retail license for the first time, the chain headquarters must complete a separate application package.

CONDITIONS OF LICENSING

Read the Conditions of Licensing thoroughly and sign. By signing it, you are agreeing to these conditions.

LICENSING FEE By law, applicants are required to pay a processing fee of $50 per location. The $50 covers required record checks and other processing costs and is not refundable.

LOTTERY RETAILER RESPONSIBILITIES

Read the Lottery Retailer Responsibilities thoroughly and sign. By signing it, you are agreeing to these conditions.

RETAILER APPLICATION

Complete the Retailer Application. Failure to complete all items may result in delay in processing or the return of your application. The following line–by–line instructions may be helpful.

1. Insert the name of your business as it is most commonly known. 2. If the legal name of the business is different from its common name, insert the legal

name.

3. Street address of the business.

4. City where business is located.

5. State where business is located.

6. Zip code of the business location.

7. The person(s) authorized to order lottery tickets.

8. Phone number of the business.

9. Hours your business is open Monday through Sunday.

10. For a sole proprietorship, list the sole owner. For a general partnership, list any partner. For a limited partnership or corporation, please list the person responsible for financial decisions and obligation for the above named business (duly authorized officer).

11. Phone number of the person listed above as “OWNER” or “PARTNER” or “DULY

AUTHORIZED OFFICER.”

12. If your mailing address is different from the street address of your business (P.O. Box, etc.), please indicate here.

13. City of mailing address if different from the city where business is located.

Rev. 8/3/2010 2 of 2

14. State of mailing address if different from the state where business is located.

15. Zip code of mailing address if different from the zip code where business is located. 16. County in which the business is located.

17. Indicate the business type that most closely describes your business. If “other,” please

describe fully.

18. Each question in the Business/Individual Information section must be marked “Yes” or “No” or the application will be returned. If any question is answered “Yes,” please provide complete details on a separate sheet.

19. Read the Certification language completely before you sign the application. The person

listed above as “OWNER” or “PARTNER” or “DULY AUTHORIZED OFFICER” must sign the application.

NOTE: Keep a copy of the Retailer Application for your records. Return the original copy to theMontana Lottery, as well as the other completed required forms and licensing fee.

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER (TIN) VERIFICATION

Fully complete this form and return it with the other required forms to the Montana Lottery, 2525 North Montana Avenue, Helena, MT 59601.

PERSONAL DATA FORM

For a sole proprietorship, the owner must complete this form. For a general partnership, submit the requested information for each individual with 10% or more interest in the business. For a limited partnership or corporation, the president and vice president must complete the form. The form must be fully completed to expedite processing of your application.

ELECTRONIC FUNDS TRANSFER AUTHORIZATION

Arrange with your bank to authorize electronic funds transfer (EFT) and complete the enclosed form. If you are not familiar with EFT, some general information regarding the process is enclosed. If you have any difficulty with your bank, contact the Lottery. If your electronic funds transfer will come from a checking account, be sure to attach a voided check as indicated with the form. Only if your electronic funds transfer will come from a savings account, attach a deposit slip instead.

Rev

CONDITIONS

CONDITIONS OF LICENSING

By completing an application, the applicant agrees:

1. That a nonrefundable licensing fee of $50 (check or money order) will accompany the Retailer Application.

2. That a license is not assignable or transferable, and the licensee agrees to immediately notify the Montana Lottery of any change in business ownership or business locations.

3. That the business may not claim to be a Lottery Retailer unless a license is granted.

4. To prominently display the license in such a manner that the license is visible and in a manner so as to prevent theft or defacing of the license.

5. That all Lottery tickets activated for sale by the licensee (except for those returned In the times and manners prescribed by the Montana Lottery) are considered to have been purchased by the licensee and are the property of the licensee.

6. To make payments for all Lottery tickets by Electronic Funds Transfer (EFT) or in accordance with other directives of the Montana Lottery.

7. To maintain authorized displays, notices, and other materials used in conjunction with Lottery ticket sales in accordance with instructions issued by the Montana Lottery.

8. To redeem winning Lottery tickets as prescribed in directives of the Montana Lottery.

9. That Lottery tickets will be sold only on the premises of the business designated on the license. Persons selling and buying Lottery tickets must be 18 years of age or older.

10. That Lottery tickets will not be sold at any price greater than the price stated on the ticket.

11. To be bound by and comply with the rules, regulations, and directives of the Montana Lottery.

12. That the licensee and all employees of the licensee who will be involved in the sale, bookkeeping, or any other aspect of the Montana Lottery will read the Lottery law and rules of the Lottery Commission concerning retail licenses and be familiar with such laws and rules.

Owner/Partner/Duly Authorized Officer (Circle One)

Name (Please print) __________________________________________________________

Signature___________________________Title_____________________ Date___________

Rev. 8/3/2010

Rev. 8/3/2010

Lottery Retailer Responsibilities Criteria for Placement and Retention of a Lottery Terminal

A retailer must first be licensed as a Lottery retailer by the Montana Lottery. This includes the retailer providing an application to the Lottery along with a $50 application fee.

Once the application has been approved, the new Lottery retailer qualifies for placement of a lotto terminal.

Location, Space, and Electrical Requirements The new retailer must sell both terminal–generated tickets and scratch tickets. Prior to receiving the lotto terminal, the new Lottery retailer must provide prominent space for the terminal and scratch ticket dispenser(s) at an agreed–upon location in the store. Neither the terminal nor the scratch ticket dispenser(s) may be moved without prior Lottery approval.

Following are the space requirements:

Lotto terminal 15" W x 17" D x 19" H Printer 6 " W x 9" D x 6" H Scratch ticket dispenser(s) Depends on scratch ticket strategy used

In addition the retailer must provide an electrical duplex–grounded outlet, operational 24 hours per day, and a 20-amp circuit breaker.

The retailer must also have a telephone near enough to the terminal location that the terminal may be operated at the same time the operator talks on the phone.

Sales Requirements The retailer must sell all terminal–generated games and at least eight scratch games, although the Lottery recommends a 16-game strategy.

The retailer must meet or exceed minimum sales requirements for a combination of terminal–generated and scratch tickets. Failure to meet assigned sales minimum may result in removal of the terminal.

Ticket Redemption Requirements The retailer must redeem winning terminal–generated and scratch tickets during all hours and days the store is open.

The retailer must pay each valid winning ticket claim of $599 or less.

Signage and Point–of–Sale Requirements The retailer must prominently display, in an agreed–upon location, current point–of–sale materials, inside and outside Lottery signage, and informational materials supplied by the Lottery.

Abiding by Statute, Rules, Procedures The retailer must abide by all provisions of the Montana Lottery statute and all rules, procedures, and instructions issued by the Lottery.

I have read the above and understand my responsibilities for receiving and retaining a lotto terminal.

Owner/Partner/Duly Authorized Officer (Circle One)

Signature Date Title

Retailer Application

Chain Name: (For Lottery Use Only) Chain Control # (For Lottery Use Only) Business Name:

Legal Name:

Address:

City: State: Zip:

Contact: Phone: ( )

Business Hours: From: To:

Owner / Partner / Duly Authorized officer:

Phone: ( ) Mailing Address:

City: State: Zip:

County:

Business Type (Check One) Convenience Store Drug Store Newsstand Service station Grocery Store/market Restaurant Bar/Lounge/Casino Liquor Store Other Does this business or the individuals listed on the Personal Data Form owe any taxes or debts to the State of Montana? YES NO Has this business or the listed individuals: *ever been sued, have outstanding claims or judgments? YES NO *ever been convicted of a felony or gambling related offense? YES NO *ever filed for bankruptcy in Montana or the US, been placed in receivership or made any assignments to creditors? YES NO *ever held or applied for or presently hold a gambling, liquor, beer or lottery license in the State of Montana or elsewhere? YES NO *ever operated under different names? YES NO IF ANY OF THE ABOVE QUESTIONS ARE ANSWERED “YES” PLEASE EXPLAIN ON A SEPARATE SHEET OF PAPER Certification I hereby certify that the foregoing information is true and complete. I understand that false or misleading statements are cause for denial of this application and/or suspension or revocation of the Lottery Retailer License. I authorize the State of Montana to investigate my financial records, financial sources, criminal history and any other matter necessary for licensing. By my signature I certify that the provided information is accurate to the best of my knowledge. Signature:

Title:

Date:

Rev. 8/3/10

Personal Data Form For a sole proprietorship, the owner must complete this form. For a general partnership, submit the requested information for each individual with 10% or more interest in the business. For a limited liability partnership or corporation, the president and vice president must complete the form. The form must be fully completed to expedite processing of your application. Business Name:

Phone Number: ( ) -

Street Address:

1. Individual’s Full Name:

A.K.A. (Maiden name, nickname, etc,)

Street Address: City: State: Zip: - SSN: - - Date of Birth: / / Relationship to Above Business: *SIGNATURE: 2. Individual’s Full Name:






Street Address: City: State: Zip: - SSN: - - Date of Birth: / / Relationship to Business: *SIGNATURE: *By my signature I authorize the Montana Lottery to investigate my financial background, criminal history and/or any other matter necessary for licensing. I certify that I have read the Conditions of Licensing and agree to comply with those conditions.

Rev. 8/3/10

Electronic Funds Transfer (EFT) Authorization THIS FORM MUST ACCOMPANY YOUR MONTANA LOTTERY RETAILER APPLICATION

FOR THE ABOVE ACCOUNT PLEASE ATTACH A VOIDED CHECK

Retailer Number: (For Lottery Use Only) Retailer Name: I hereby authorize the Montana Lottery to initiate debit/credit entries into my (check one of the following):

Checking Account or Savings Account indicated below, and the Financial Institution below, to debit/credit same to such account. Financial Institution: City: State: Zip: Account No. This authority is to remain in full force and effect until the Montana Lottery and my Financial Institution have received written notification from me of its termination in such time and in such manner as to afford the Montana Lottery and my Financial Institution a reasonable time to act on it. (Circle One) Owner / Partner / Duly Authorized Officer Name:

OR FOR A SAVINGS ACCOUNT ATTACH A SAVINGS DEPOSIT SLIP.

Signature: Signature of Owner Partner or Corporate Governing Officer Title Date

Substitute Form

W-9 REQUEST FOR TAXPAYER IDENTIFICATION

NUMBER (TIN) VERIFICATION

State of Montana Do NOT send to IRS

PRINT OR TYPE

Legal Name (OWNER OF THE EIN OR SSN AS APPEARS ON IRS OR SOCIAL SECURITY ADMINISTRATION RECORDS) DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS LINE-See Reverse for Important Information

Trade Name COMPLETE ONLY IF DOING BUSINESS AS (DBA)

Remit Address

RETURN TO ADDRESS BELOW

Purchase Order Address – Optional

PART II See Part II Instruction on Back of Form

Check legal entity type and enter 9 digit Taxpayer Identification Number (TIN) below: (SSN = Social Security Number EIN = Employer Identification Number)

Do Not enter an SSN or EIN that was not assigned to the legal name entered above

Individual (Individual’s SSN)

NOTE: If no name is circled on a Joint Account when there is more then one name, the number will be considered to be that of the first name listed. Sole Proprietorship (Owner’s SSN or Business FEIN) SSN

NOTE: Enter both the owner’s SSN and the Business EIN (if you are required to have one)

EIN EFFECTIVE DATE OF EIN Partnership General Limited (Partnership’s EIN)

EFFECTIVE DATE OF EIN

Estate / Trust (Legal Entity’s EIN) NOTE: Do not furnish the identification number of personal representative or trustee unless the legal entity itself is not designated in the account title. List and circle the name of the legal trust, estate or pension trust. EFFECTIVE DATE OF EIN

Other Please specify (Entity’s EIN) Limited Liability Company, Joint Venture, Club, etc. EFFECTIVE DATE OF EIN

Corporation Do you provide legal or medical services? Yes No (Corp’s EIN) Includes corporations providing medical billing services EFFECTIVE DATE OF EIN

Government (or Government Operated) Entity (Entity’s EIN) EFFECTIVE DATE OF EIN

Organization Exempt from Tax under Section 501(a) (Org’s EIN)

Do you provide medical services? Yes No EFFECTIVE DATE OF EIN Check here if you do not have a SSN or EIN, but have applied for one. See reverse for information on How to Obtain a TIN.

Licensed Real Estate Broker? Yes No Exempt from backup withholding? Yes No

Under Penalties of perjury, I certify that:

1. The number listed 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 n ot subject to b ackup withholding because: (a) I am ex empt from backup withholding, or (b) I hav e not been notified by the Internal Revenue service (IRS) that I am su bject 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 su bject t o backu p wit hholding (do es n ot apply to re al es tate transactions, mortgage inte rest paid, the acquisition of ab andonment o f se cured property, contribution to an individual retirement arrangement (IRA), and payments other than interest and dividends). CERTIFICATION INSTRUCTIONS – Yo u must cross out item (2) above i f you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return. (See Signing the Certification on the reverse of this form.)

THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING

Name (Print or Type)

Title (Print or Type)

Signature of U.S. Person

Date

Phone( )

E-Mail Address (Print or Type)

DO NOT WRITE BELOW THIS LINE

RETURN TO ADDRESS ABOVE

AGENCY USE ONLY Agency Approved By Date 1099 Yes No Vendor Addition Change Action Completed By Date 615-82-50-7093 (R 2/06)

NAME AND TAX IDENTIFICATION NUMBER (TIN) P

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INDIVIDUALS: Enter First and Last name EXACTLY as it appears on your So cial Security Card. However, if you have changed your last name, for in stance, due to marriage, without informing the S ocial Security Administration of th e name change, please enter your first name and both the last name shown on your social security card and your new last name (IN THAT ORDER). For your TIN, enter your Social Security Number (SSN).

SOLE PROPRIETORSHIPS: Enter the owner’s name on the first line; on the second name line you may enter the business name. YOU MAY NOT ENTER ONLY THE BUSINESS NAME. For the TIN, enter both the owner’s Social Security Number and the Federal Employer Tax Identification Number (EIN) if you are required to have one.

ALL OTHER ENTITIES: Enter the name of the owner of the EIN or SSN exactly as originally registered with the IRS. The correct TIN is the Employer Identification Number (EIN).

DO NOT ENTER AN SSN OR EIN THAT WAS NOT ASSIGNED TO THE LEGAL NAME OF THIS FORM

HOW TO OBTAIN A TIN If you do not have a TIN, you should apply for one immediately. To apply for the number, obtain Form SS-05, Application for a S ocial Security Number Card (for individuals), or Form SS-4, Application of Employer Identification number (for businesses and all other entities), at your local office of the Social Security Administration or the Internal Revenue Service. Complete and file the appropriate form according to its instructions.

To complete Form W-9 if you do not have a TIN, check “Applied For” box in the space indicated on the f ront, sign and date the form, and give it to the requester. For payments that could be subject to backup withholding, you will then have 60 days to obtain a TIN and furnish it to the requester. During the 60-day period, the payments you receive will not be subject to the 31% backup withholding, unless you make a withdrawal. However, if the requester does not receive your TIN from you within 60 days, backup withholding, if applicable, will begin and continue until you furnish your TIN to the requester.

NOTE: Writing “Applied For” on the form means that you have already applied for a TIN OR that you intend to apply for one in the near future.

As soon as you receive your TIN, complete another Form W-9, include your new TIN, sign and date the form, and give it to the requester.

FOR PAYEES EXEMPT FROM BACKUP WITHHOLDING

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II Individuals (in cluding sole prop rietors) ar e n ot exempt f rom backup withholding. Corporations are exempt from backup withholding for

certain payments, such as interest and dividends.

If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. Enter your correct TIN in Part I, write ‘Exempt’ in Part II and sign and date the form.

If you are a nonr esident alien or f oreign entity not subject to backup withholding, g ive the r equester a co mpleted Form W-8, Certificate of Foreign Status.

+ CERTIFICATION

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III

1) Interest, Dividend, and Barter Exchange Accounts Opened Before 1984 and Broker Accounts That Were Considered Active During 1983. – You are not required to sign the certification; however, you may do so. You are required to provide your correct TIN.

(2) Interest, Dividend, Broker and Barter Exchange Accounts Opened After 1983 and Broker Accounts That Were 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 if you wish.

(4) Other Payments – You are required to furnish your correct TIN, but you are not requi red to sign the ce rtification unless yo u have been n otified o f an in correct TI N. Oth er pa yments in clude payments ma de in the course of t he r equester’s tra de o r business f or rents, royalties, g oods (other th an bi lls fo r merchandise), m edical and heath care services, pa yments t o a n onemployee fo r s ervices (i ncluding attorney and accounting fees), and payments to certain fishing boat crew members.

(5) Mortgage Interest Paid by You, Acquisition or Abandonment of Secured Property, or IRA Contributions. – You are required to furnish your correct TIN, but not required to sign the certification.

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Signature. – The signature should be an authorized signature, generally the person whose name is on the top line of the form, a partner in the partnership, or an officer of the corporation. For joint account, only the person whose TIN is shown in LEGAL BUSINESS DESIGNATION should sign the form.

Privacy Act Notice. – Section 6109 requires you to furnish your correct taxpayer identification number (TI N) to per sons who must file information returns w ith t he IR S to repo rt in terest, di vidends, and c ertain o ther in come pa id t o yo u, mo rtgage in terest you pa id, th e acquisition or aband onment of sec ured p roperty, or c ontributions you ma de to an individual r etirement a rrangement (IRA). I RS u ses t he numbers fo r i dentification pu rposes an d to h elp verify a ccuracy of yo ur ta x return. Yo u mu st p rovide yo ur TI N whether o r n ot you are required to file a tax return. Payers must generally withhold 31% of taxable interest, dividend, and certain other payments to a payee who does not furnish a TIN to a payer. Certain other penalties may also apply.

Rev. 8/3/2010

THE MOST FREQUENTLY ASKED QUESTIONS AND ANSWERS REGARDING ELECTRONIC FUNDS TRANSFER

1. What is Electronic Funds Transfer (EFT)?

EFT is a process by which an account can be automatically debited and/or credited (once permission is obtained from the depositor) without having to write and mail a check. The system is precise because it utilizes the telecommunications network of the Federal Reserve to link your bank with the Montana Lottery’s bank. An Automated Clearing House (ACH) acts as a middleman to route funds to the proper accounts.

2. What are the advantages in using the EFT system?

A) You are assured the funds are received. B) You will know exactly when your account will be debited. The transaction will occur at the same

time every collection cycle. C) The cost of writing and mailing a check is eliminated.

3. Do I have to participate in EFT?

All Montana Lottery retailers are required to participate in the system.

4. Is a separate Lottery account advisable?

This decision will be left to you. Whatever is easiest for you is fine with us. If you choose to open a separate account for the EFT transfers, you will be able to keep the Lottery transactions separate from your regular account, but your bank may charge extra for maintaining a separate account. You should discuss that with your bank.

5. Can I use my present bank for EFT?

In most cases, yes. However, in Montana, there are still a few banks that have difficulty handling EFT. You should contact your bank to determine if there may be a problem with using your present account.

6. What steps do I take with my bank so I can participate in the EFT system?

Simply open a bank account (or use an existing account) and make your bank aware there will be EFT transactions processed against your account. Notify the Lottery of your account number and transit routing number by completing and returning the EFT Authorization Form with your Retailer Application.

7. Whose name should be on the account?

You should use the business name exactly as it appears on your Montana Lottery Retailer Application.

8. How much will it cost for this service?

The transaction charges and/or service charges Lottery retailers pay vary with different banks. In mostcases these charges have been reasonable. Your bank charges should be considered when determining how much money to deposit in an account to cover the EFT sweep.

9. Can I earn interest on this account?

You should check with your bank regarding the feasibility of using an interest bearing account.

Rev. 8/3/2010

10. Can this account be used by the Lottery to monitor my account? The Lottery can only debit or credit your account. The Lottery has no way of monitoring your activity or balances.

11. How do I know when my account will be swept and for how much?

Your account will be swept weekly for all monies due from the prior accounting week (Sunday throughSaturday). Each Wednesday morning your lottery terminal will produce a settlement report for the prior accounting week. This report shows the total amount of your weekly sweep.

12. When must my money be deposited in the EFT account for transfer to the Lottery?

You should deposit the money into your EFT Account no later than 3 p.m. on Wednesday.

13. What will happen if the proper amount of money is not in my EFT account at the time the transfer to the Lottery is effected?

Even if your EFT account is just one cent short of having enough money at the time of the EFT transfer, the entire transaction will be returned to us as a Non-Sufficient Funds (NSF). The Lottery has established the following policy for handling NSF. When the first NSF is received from Federal Reserve, you will be contacted and asked to send us a cashier’scheck or money order to cover the NSF. If we receive a second NSF notice from Federal Reserve, we may automatically inactivate your lottery terminal until payment in full is received. This procedure will stop all orders and deliveries until your lottery terminal is reactivated. We will then review your payment history and take appropriate action, which could include revocation of your Lottery retailer license. Any non-sufficient fund (NSF) charges assessed by your bank will be your responsibility.

14. What do I do if I have a problem with my invoice but don’t want to risk the Lottery getting a NSF

notice?

Immediately call Lottery Accounting on our toll free number, 1-800-443-5708, to discuss the problem. A determination will be made at that time regarding payment.

15. Can third party checks be deposited to the EFT account?

Checks can take a number of days to clear and become “available money.” If checks are deposited into the EFT account, you should take into consideration that it could be several days before monies are available for EFT sweeps.

16. Can I pay winning tickets with checks drawn against the EFT account?

Yes. Just be sure that checks written do not draw your account balance below the amount required foryour next EFT sweep.

17. Who do I call if I have a problem with the EFT system?

If you experience a problem with the EFT system, contact Lottery Accounting on our toll free number, 1-800-443-5708.

18. What do I do if I need to change my EFT account?

If you need to change your EFT account, please contact Lottery Accounting on our toll free number, 1-800-443-5708, at least two weeks in advance. You will need to complete the Change in EFT Account Authorization form.

retailer application

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