Blank Florida Lottery Dol 129 PDF Form

Blank Florida Lottery Dol 129 PDF Form

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.

Document Sample

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)

1

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)

 

Phone

 

Title

 

 

Birthdate (MM-DD-YY)

Home Address

City

State

Zip

Sex

Race

% Ownership

Social Security Number

Name (first, middle initial, last)

 

Phone

 

Title

 

 

Birthdate (MM-DD-YY)

Home Address

City

State

Zip

Sex

Race

% Ownership

Social Security Number

Name {first, middle initial, last)

 

Phone

 

Title

 

 

Birthdate (MM-DD-YY)

Home Address

City

State

Zip

Sex

Race

% Ownership

Social Security Number

Name {first, middle initial, last)

 

Phone

 

Title

 

 

Birthdate (MM-DD-YY)

Home Address

City

State

Zip

Sex

Race

% Ownership

Social Security Number

Name (first, middle initial, last)

 

Phone

 

Title

 

 

Birthdate (MM-DD-YY)

Home Address

City

State

Zip

Sex

Race

% Ownership

Social Security Number

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

Yes No

c. Been arrested and have any pending criminal charges that have not been resolved?

Yes

No

d. Been a Florida Lottery Retailer?

Yes

No

e. Been suspended or terminated as a Florida Lottery Retailer?

Yes

No

f. Been subject to any adverse actions or findings as a lottery retailer with any other state lottery within

 

 

the continental United States?

Yes

No

If yes to questions a, b, c, d, e, or f, please explain response and include dates below (use additional sheet if necessary).

DOL-129 (Revised 4/19)

2

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)

 

 

Title

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.

DOL-129 (Revised 4/19)

3

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.

Yes

No

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

Date

4

DOL-129 (Revised 4/19)

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.

5

DOL-129 (Revised 4/19)

File Specifics

Fact Name Description
Application Fee Structure The Florida Lottery DOL 129 form requires a non-refundable application fee. The initial application fee is $100, while additional locations cost $25, changes of location cost $10, and new officers, directors, or shareholders incur a fee of $25 each.
Background Investigation Each applicant must undergo a background investigation, which may include fingerprinting. This process ensures the integrity of the lottery system.
Bond Requirement If the background investigation indicates a need, the retailer applicant must post a bond or other security to secure payment of lottery proceeds.
Governing Law The Florida Lottery DOL 129 form is governed by Section 24.112 of the Florida Statutes, which outlines the requirements and procedures for becoming a lottery retailer.

How to Use Florida Lottery Dol 129

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.

  1. Start by entering your Florida Lottery ID number and Chain number at the top of the form.
  2. Indicate the type of application you are submitting by checking the appropriate box: Initial Application, 100% Sale of Stock, New Officer(s), Director(s), Shareholder(s), Additional Store Location, Change of Location, or Change of Ownership.
  3. Fill in the date of relocation if applicable.
  4. Provide your business information in Section 1, including:
    • Corporate or other legal name
    • Store name (doing business as)
    • Store phone number
    • Store address (including street, city, state, zip code, and county)
    • Mailing address, if different from the store address
    • Contact name and title
    • Contact numbers and email address
    • Taxpayer identification number
    • Florida sales tax number
    • Alcoholic beverage license number, if applicable
    • Minority business status
    • Business type
    • Florida Department of State, Division of Corporations document number
  5. In Section 2, provide officer/owner information:
    • Answer whether any individuals listed are related to a Florida Lottery employee.
    • List all owners, individual partners, managing members, corporate officers, directors, and shareholders with 10% or more interest in the business.
    • Answer questions regarding any criminal history or previous lottery retailer status.
  6. If applicable, provide additional information for non-U.S. citizens listed in Section 2.
  7. Indicate how you learned about becoming a Florida Lottery retailer.
  8. Sign and date the certification section, ensuring you understand the implications of the information provided.
  9. Have the form notarized, if required, by a notary public.
  10. Submit the completed form along with the non-refundable application fee via check or money order to the Florida Lottery.

Your Questions, Answered

What is the purpose of the Florida Lottery DOL 129 form?

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.

What fees are associated with the DOL 129 form?

There are several fees related to the DOL 129 application process:

  • Initial Application: $100
  • Additional Location: $25
  • Change of Location: $10
  • New Officer, Director, or Shareholder: $25 each

These fees are non-refundable and must be paid by check or money order made out to the Florida Lottery.

What information is required on the DOL 129 form?

The DOL 129 form requires detailed information, including:

  1. Business name and address
  2. Contact information for the applicant
  3. Taxpayer identification numbers
  4. Details about the business type and ownership
  5. Any previous criminal convictions or lottery-related history of the owners

Completing the form accurately is crucial, as inaccuracies may lead to rejection of the application.

What happens after submitting the DOL 129 form?

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.

Are there any requirements for business accessibility?

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.

Can the information on the DOL 129 form be kept confidential?

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.

Common mistakes

  1. Failing to provide the Florida Lottery ID# and CHAIN#. This information is essential for processing the application.

  2. Not checking the correct application type. Ensure that the appropriate box is selected for the application type being submitted.

  3. Leaving out critical business information. Missing details such as the STORE NAME or STORE ADDRESS can delay the application.

  4. Providing inaccurate contact information. Ensure that all phone numbers and email addresses are correct and current.

  5. Omitting the TAXPAYER IDENTIFICATION NUMBER. This number is required for tax reporting and verification purposes.

  6. Not disclosing any relevant criminal history. This includes failing to answer questions regarding past convictions or pending charges.

  7. Forgetting to sign the application. An unsigned application will be considered incomplete and will not be processed.

  8. Neglecting to include the non-refundable application fee. Ensure that the correct amount is enclosed with the application.

Documents used along the form

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.

  • Background Investigation Consent Form: This form grants permission for the Florida Lottery to conduct a thorough background check on the applicant and any individuals associated with the business. It typically includes fingerprinting requirements and personal information for verification.
  • Bond or Security Agreement: Depending on the results of the background investigation, applicants may need to submit a bond, certificate of deposit, or another form of security. This document ensures the payment of lottery proceeds and protects the interests of the Florida Lottery.
  • Business License: A copy of the business license is often required to confirm that the applicant is legally allowed to operate a business in Florida. This document verifies compliance with local, state, and federal regulations.
  • Tax Identification Documents: Applicants must provide their taxpayer identification number, which is essential for tax reporting purposes. This may include the Social Security Number for sole proprietors or the Federal Employer Identification Number for other business entities.
  • Retailer Awareness and Integrity Training Certificate: Completion of a training program on retailer responsibilities and integrity is typically required. Applicants must submit a certificate indicating that they have successfully completed this training.

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.

Similar forms

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.

Dos and Don'ts

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.

  • Do: Print or type all information clearly to avoid misinterpretation.
  • Do: Ensure that the application fee is paid in full by check or money order.
  • Do: Provide accurate and complete contact information for all individuals listed.
  • Do: Review the form for any missing signatures or required fields before submission.
  • Do: Be honest when answering questions regarding criminal history and background checks.
  • Don't: Submit the application without verifying that all information is accurate.
  • Don't: Leave any sections blank; if a question does not apply, indicate that clearly.
  • Don't: Provide false information, as this can lead to rejection of the application.
  • Don't: Forget to include any additional sheets if more space is needed for answers.
  • Don't: Assume that all information is confidential; note that some details may be publicly accessible.

Misconceptions

  • Misconception 1: The DOL 129 form is only for new retailers.
  • 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.

  • Misconception 2: There are no fees associated with the DOL 129 form.
  • 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.

  • Misconception 3: Background checks are optional for applicants.
  • This is false. All applicants are subject to mandatory background investigations, which may include fingerprinting. This requirement ensures the integrity of the lottery system.

  • Misconception 4: The information provided on the DOL 129 form is confidential.
  • 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.

Key takeaways

Filling out the Florida Lottery DOL 129 form requires careful attention to detail. Here are key takeaways to ensure a smooth application process:

  • Application Fees: The initial application fee is $100, while additional location requests cost $25. Changes of location or ownership incur a fee of $10 and $25, respectively.
  • Background Investigation: All applicants must undergo a background investigation, which may include fingerprinting.
  • Bond Requirement: A bond or other security may be necessary if the background check indicates it is needed to secure lottery proceeds.
  • Business Information: Accurate business details, including legal name, store name, and taxpayer identification number, must be provided.
  • Ownership Disclosure: List all owners, partners, and shareholders with a 10% or more interest in the business, including their personal information.
  • Criminal History: Disclose any felony convictions or gambling offenses for the past ten years for all listed individuals.
  • Accessibility Compliance: Ensure the business location complies with accessibility requirements under Florida law.
  • Public Disclosure: Information in the application is subject to public inspection, so accuracy and honesty are paramount.

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.