The Florida Lottery DOL 129 form is an application required for individuals or businesses wishing to become retailers for the Florida Lottery. This form collects essential information about the applicant, including business details and ownership structure, while also ensuring compliance with state regulations. To get started, fill out the form by clicking the button below.
The Florida Lottery Dol 129 form is a crucial document for individuals and businesses seeking to become authorized lottery retailers in the state of Florida. This form serves as the retailer application and requires applicants to provide detailed information about their business, including the legal name, store name, and contact details. Applicants must also pay a non-refundable application fee, which varies based on the type of application being submitted, such as an initial application, change of location, or new officer. A background investigation is mandatory for all applicants, and this may include fingerprinting. Additionally, the form requires information about ownership, including details on any individuals who hold a significant stake in the business. It is essential for applicants to disclose any criminal history, as this may impact their eligibility. The form also collects information related to the business type and compliance with accessibility requirements, ensuring that all lottery retailers adhere to state regulations. Understanding the requirements and completing the Dol 129 form accurately is vital for a successful application process.
RETAILER APPLICATION
FOR LOTTERY USE ONLY
Florida Lottery
ID#___ CHAIN#___
250 Marriott Drive
PROSPECT#______
Tallahassee, FL 32399-6573
(850) 487-7714 or flalottery.com
DO___________
Non-refundable Application Fee: Payable to the Florida Lottery by check or money order.
Initial Application $100, Additional Location $25, Change of Location $10,
New Officer, Director or Shareholder $25 each.
Each applicant shall be subject to a background investigation which can include fingerprinting.
A retailer applicant shall be required to post a bond, certificate of deposit or other security if it is determined during the background
investigation that such requirement is necessary to secure payment of lottery proceeds.
Check application type and complete the information below - PLEASE PRINT OR TYPE:
0 INITIAL APPLICATION O100% SALE OF STOCK O NEW OFFICER(S), DIRECTOR(S), SHAREHOLDER(S) 0 ADDITIONAL STORE LOCATION
0 CHANGE OF LOCATION: Date of Relocation ____________
0 CHANGE OF OWNERSHIP: Previous Location ID#___________ Date of Sale _______
For information concerning sale of business: Contact Name ________ Phone Number ( ___
SECTION 1 - BUSINESS INFORMATION
1.CORPORATE OR OTHER LEGAL NAME: ________________________
2.STORE NAME (dba): _______________ 3. STORE PHONE: { __ } __ - ___
4.STORE ADDRESS: _______________________________
StreetCityState Zip Code County
_
5. MAILING ADDRESS: _____________________________
SameasStoreAddressO Street or P.O. Box
City
State
Zip Code
6. CONTACT NAME AND TITLE: ___________________________
First
Middle Initial
Last
Title
7. CONTACT NUMBERS AND E-MAIL ADDRESS:
{ __} __-____
{ __} __- ____
Phone
Alternate Phone
Fax Number
E-mail Address
8.TAXPAYER IDENTIFICATION NUMBER: Provide number used to file business income tax return.
Sole Proprietors, list Social Security Number. All other entities, list Federal Employer Identification Number.
9.FLORIDA SALES TAX NUMBER: _ _ - _ _ _ _ _ _ _ _ _ _ - _ 0 Applied For O Tax Exempt
10. ALCOHOLIC BEVERAGE LICENSE NUMBER: __-_____
0 Applied For O Not Applicable
11.
MINORITY BUSINESS: 0 YES
ONO (If yes, check appropriate minority category)
African American
Native American
_ Hispanic American
American Woman
Asian American
12.
BUSINESS TYPE: (Check One)
_ Partnership
Non Profit
_ Sole Proprietorship
_ Corporation
_ Limited Partnership
_ Limited Liability Company
_ Limited Liability Partnership
13.
FLORIDA DEPT. OF STATE, DIVISION OF CORPORATIONS DOCUMENT NUMBER: ____________
DOL-129 (Revised 4/19)
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SECTION 2 - OFFICER/OWNER INFORMATION
THE LOTTERY SHALL NOT CONTRACT WITH ANY PERSON WHO IS RELATED TO AND RESIDING WITH ANY EMPLOYEE OF THE LOTTERY.
1.Are any of the individuals listed below related to an employee of the Florida Lottery in one of the following ways: husband, wife, parent, grandparent, spouse's parent, child, brother, sister, spouse of a child, aunt, uncle, grandchild, niece, nephew, first cousin, and living in the same household as the employee? ____ Yes ___No
2.LIST ALL OWNERS, INDIVIDUAL PARTNERS, MANAGING MEMBERS, CORPORATE OFFICERS, DIRECTORS. LIST
SHARE-HOLDERS OF 10% OR MORE OR LIMITED PARTNERS WITH 10% OR MORE INTEREST IN THE BUSINESS. IF MORE SPACE IS REQUIRED, PLEASE ATTACH ADDITIONAL SHEETS.
Name (first, middle initial, last)
Birthdate (MM-DD-YY)
Home Address
Zip
Sex
Race
% Ownership
Social Security Number
Name {first, middle initial, last)
3.Have any of the individuals listed above:
a.Been convicted of, or pleaded guilty or nolo contendere to a felony within the last 10 years, regardless of adjudication?
b.Been convicted of, or pleaded guilty or nolo contendere to any gambling offense within the last 10 years, regardless of adjudication?
Yes No
c. Been arrested and have any pending criminal charges that have not been resolved?
Yes
No
d. Been a Florida Lottery Retailer?
e. Been suspended or terminated as a Florida Lottery Retailer?
f. Been subject to any adverse actions or findings as a lottery retailer with any other state lottery within
the continental United States?
If yes to questions a, b, c, d, e, or f, please explain response and include dates below (use additional sheet if necessary).
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4.For any individuals listed in the Officer/Owner Information, Section 2, who are not U.S. citizens, please list the individual's name, mother's maiden name, father's name; passport number, permanent resident or 1-94 number; the last permanent address prior to entering the U.S. and the last date of entry into the U.S.
How did you learn about becoming a Florida Lottery Retailer? Check one:
D Sales Rep Visit
D Florida Lottery Website
D Word of Mouth
D Direct Mail
D Print Ad
D Florida Business Information Portal
D Other: Please Specify
Certification:
An attorney in fact may not make any affidavit as to the personal knowledge of the principal.
I HEREBY CERTIFY that the information contained on this form or otherwise submitted to the Florida Lottery in connection with my application to become a retailer is true and correct in every material respect. I understand that providing inaccurate or misleading information is grounds for rejection of this application or cancellation of the Retailer Contract. The Florida Lottery is authorized to obtain criminal background, Florida tax, credit, and general information about me, my business, and any persons listed on this application, which may assist in making a decision on this application. The business location where lottery tickets will be sold is in compliance with the accessibility requirements set forth in sections 553.501 - 553.513, Fla. Stat., the Florida Americans with Disabilities Accessibility Implementation Act.
I HEREBY CERTIFY I have read and understand the content contained in the Retailer Awareness and Integrity Training document found on the Florida Lottery's website at flalottery.com/HowToApply.
State of _______________
Signature of Authorized Corporate Officer, Partner, or Owner
County of _______________
Sworn to or affirmed and subscribed before me this
Print or type name
________ day of ______, ___,
(Day)
(Month)
(Year)
by _______________
(Name of Authorized Corporate Officer, Partner, or Owner)
Signature of Notary Public
(Print, Type or Stamp Commissioned Name of Notary Public)
__ Personally Known or __ Produced Identification
Type of
Affix Notary stamp above.
Identification ______________
Certificates of Authority and retailer contracts are not assignable or transferable between persons or locations. STATEMENT OF PUBLIC DISCLOSURE: Information contained in this application shall be open to the public for inspection.
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MARKETING EVALUATION/SITE SURVEY
Store Name: ---------------- COMPLETE WITH LOTTERY SALES REPRESENTATIVE
1.TRADE STYLE (Circle One)
Airport Location
Convenience Store
Hardware/Building Supplies
Restaurant - No Liquor
Appliances
no gas pumps
Hotel/Motel
Shopping Mall Location
Auto Parts/Repair
Convenience Store-
Ice Cream Shop
Small Grocery/Meat/Fish Market
Bakery
with gas pumps
Jewelry Store
Sports Arena/Amusement Park
Bar/Tavern/Lounge
Department Store
Laundry/Dry Cleaner
Supermarket
Barber Shop/Hairdresser
Dollar Store/Discount Store
Mail Services/Copy Center
Telecommunications Center
Beauty Shop
Drug Store/Pharmacy
Municipality/Political Subdivision
Travel Agency
Bingo Hall
Financial Services
Newsstand/Tobacconist/Sundries
Travel Plaza/Truck Stop
Bowling Alley
Flea Market
Non-Profit Organization
Wholesale Club
Car Wash
Florist
Package Liquor Store
Other ________
Clothing/Shoes
Gas Station/Auto Repair
Pari-Mutuel
Coffee/Deli/Sub Shop
Gift/Card Shop
Restaurant - Liquor
2. BUSINESS OPERATION:
0 SEASONAL BUSINESS
0 YEAR-ROUND BUSINESS
Business Hours
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
FROM
TO
3. RETAILER INSTALLATION INFORMATION:
■ Yes
■ No
New Construction or Store Not Yet Open? Please Check.
If yes, complete a, b, & c below.
a. Store opening date:___________
b. Approximate date for terminal and communications equipment installation:__________
c. Building contact name and phone number: _____________________
Retailer Owns Location? Please Check.
If no, complete a & b below.
Retailers with a lease agreement must have their landlord's approval for the installation of communications equipment on the roof and the installation of cables inside the location.
a.Landlord contact name:---------------------------------
b.Landlord phone number:_________________________________
4.COMMENTS:
Sales Representative: -----------------------------------
Lottery Sales Representative Signature
SR#
Stop#
Date
Lottery District Manager:
Lottery District Manager Signature
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PRIVACY ACT NOTICE
RETAILER APPLICANTS
Under the Federal Privacy Act, disclosure of a person's Social Security number is voluntary unless a Federal statute specifically requires such disclosure or allows states to collect the number. In connection with filing an application to become a Florida Lottery retailer, disclosure of the applicant's Social Securtiy number is required by 26 U.S.C.A. s. 6109 for tax reporting purposes. The applicant's Social Security number will also be used in performing the background investigation necessary to implement Section 24.112, Florida Statutes, because the Social Security number is used as an identifier in the databases searched.
The Lottery may also provide this information to law enforcement agencies to enforce criminal laws.
Under Section 119.071(5), Florida Statutes, an agency may collect Social Security numbers if it is imperative for the performance of the agency's duties and responsibilities. Notice is hereby provided that for retailer applicants that are legal entities, it is imperative that the Lottery use the Social Security numbers of members, partners, officers, directors, etc., to conduct the background investigations necessary to implement Section 24.112, Florida Statutes, because the Social Security number is used as an identifier in the databases searched.
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Completing the Florida Lottery DOL 129 form is an important step in the application process to become a retailer. Once you have filled out the form, it will be submitted for review, and you will be contacted regarding the next steps, which may include a background investigation and potential approval of your application.
The Florida Lottery DOL 129 form is an application for individuals or businesses seeking to become authorized retailers for the Florida Lottery. This form collects essential information about the business and its owners, which is necessary for conducting background checks and ensuring compliance with state regulations.
There are several fees related to the DOL 129 application process:
These fees are non-refundable and must be paid by check or money order made out to the Florida Lottery.
The DOL 129 form requires detailed information, including:
Completing the form accurately is crucial, as inaccuracies may lead to rejection of the application.
Once the DOL 129 form is submitted, the Florida Lottery will conduct a background investigation. This may include fingerprinting and a review of the applicant's criminal history, tax compliance, and financial standing. The lottery will then make a decision on whether to approve the application.
Yes, the business location where lottery tickets will be sold must comply with the accessibility requirements set forth in Florida Statutes. This ensures that the location is accessible to individuals with disabilities.
No, the information provided on the DOL 129 form is subject to public disclosure. Under Florida law, this information is open to inspection by the public, so applicants should be aware that their details may not be kept confidential.
Failing to provide the Florida Lottery ID# and CHAIN#. This information is essential for processing the application.
Not checking the correct application type. Ensure that the appropriate box is selected for the application type being submitted.
Leaving out critical business information. Missing details such as the STORE NAME or STORE ADDRESS can delay the application.
Providing inaccurate contact information. Ensure that all phone numbers and email addresses are correct and current.
Omitting the TAXPAYER IDENTIFICATION NUMBER. This number is required for tax reporting and verification purposes.
Not disclosing any relevant criminal history. This includes failing to answer questions regarding past convictions or pending charges.
Forgetting to sign the application. An unsigned application will be considered incomplete and will not be processed.
Neglecting to include the non-refundable application fee. Ensure that the correct amount is enclosed with the application.
The Florida Lottery Dol 129 form is a crucial document for individuals or businesses applying to become lottery retailers in Florida. Along with this form, several other documents and forms are often required to complete the application process. Below is a list of commonly used forms and documents that accompany the Dol 129 form.
These documents collectively facilitate the application process for becoming a Florida Lottery retailer. Ensuring that all required forms are completed accurately and submitted on time is essential for a successful application.
The Florida Lottery Dol 129 form shares similarities with the IRS Form SS-4, which is used to apply for an Employer Identification Number (EIN). Both forms require detailed information about the business, including the legal name, address, and type of entity. Just as the Dol 129 mandates background checks for lottery retailer applicants, the IRS form necessitates that applicants provide information about their business structure and ownership. Both forms serve as a means for regulatory authorities to ensure compliance with legal and financial obligations, thereby protecting the integrity of the respective systems.
Another document comparable to the Dol 129 is the state business license application. This application typically requires information about the business owner, the nature of the business, and its location. Similar to the Dol 129, it often includes a certification section where the applicant must attest to the truthfulness of the information provided. Both documents aim to verify that businesses meet specific criteria before they can legally operate, ensuring that they adhere to local regulations and standards.
The liquor license application form is also akin to the Dol 129. Both documents require extensive background information on the business owners and any partners involved. Just as the Dol 129 includes sections on criminal history, liquor license applications often ask about any past violations related to alcohol sales. This parallel highlights the importance of maintaining responsible business practices in regulated industries, ensuring that only qualified individuals are permitted to operate within these sectors.
In addition, the application for a sales tax permit shares similarities with the Dol 129 form. Both require applicants to disclose their business structure and provide taxpayer identification numbers. Each form serves as a means for state authorities to monitor business activities and ensure compliance with tax regulations. The information collected helps the state maintain accurate records and enforce tax laws effectively, similar to the objectives of the Florida Lottery in regulating its retailers.
The professional license application is another document that resembles the Dol 129. This application often requires personal and professional information about the applicant, including educational background and work history. Just like the Dol 129, it includes a section for disclosures regarding any criminal history. Both forms are designed to assess the qualifications and integrity of applicants, ensuring that only suitable individuals are granted the right to operate in their respective fields.
Lastly, the business partnership agreement can be compared to the Dol 129 form. While the partnership agreement outlines the roles and responsibilities of each partner, it also requires identification of all parties involved, similar to the Dol 129's request for information about business owners and officers. Both documents aim to establish clear expectations and legal frameworks, ensuring that all stakeholders are aware of their obligations and rights within the business structure.
When completing the Florida Lottery DOL 129 form, it is important to follow specific guidelines to ensure accuracy and compliance. Below is a list of recommended practices and common pitfalls to avoid.
This is incorrect. The DOL 129 form can be used for various purposes, including changes of location, ownership, and updates for new officers or shareholders. It is not limited to initial applications.
In reality, there are specific non-refundable fees tied to the application process. For instance, an initial application incurs a fee of $100, while additional locations and changes of ownership have their own fees as well.
This is false. All applicants are subject to mandatory background investigations, which may include fingerprinting. This requirement ensures the integrity of the lottery system.
Contrary to this belief, information submitted in the application is subject to public disclosure. This transparency is part of the regulatory framework governing the Florida Lottery.
Filling out the Florida Lottery DOL 129 form requires careful attention to detail. Here are key takeaways to ensure a smooth application process:
Completing the DOL 129 form correctly is essential for a successful application to become a Florida Lottery retailer. Each section requires specific information that must be filled out accurately to avoid delays or rejections.