ILLINOIS GAMING BOARD 160 N. LaSalle Street, Suite 300 Chicago, Illinois 60601-3103 ILLINOIS GAMBLING ACT & SPORTS WAGERING ACT BUSINESS ENTITY DISCLOSURE FORM Name of Business Entity: Doing Business As: (an assumed name must be registered with the Secretary of State) Address: Mailing Address: (if different than above) Telephone #: ________________________________________ Facsimile _________________________________________ FEIN/Identification number*: _____________________ Illinois Business Tax number (if applicable)**:_______________________ Affiliated Applicant/Licensee: __________________________________________________________________________________ Please indicate below the type of Applicant/License for which this Form is submitted (check all that apply): Owner’s License Organization Gaming License Master Sports Wagering License Management Services Provider License Tier 2 Official League Data Provider License Supplier’s License -specify Casino/Riverboat Supplier Sports Wagering Supplier Business Entity’s Position/Relationship to Applicant/Licensee (check all that apply) Shareholder Shareholder of Parent or Subsidiary Partner Other LLC Member *If Applicant does not hold a FEIN number, state the proposed date for obtaining such number and the Internal Revenue Service District where federal tax filings will occur. **Depending on the nature of its business, the Business Entity may be required to register with the Department of Revenue and pay certain taxes. To inquire as to the applicability of these registration requirements, contact the Department of Revenue (Central Registration Division) at 217-785-2889. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- Authorized Agent Name/Title:__________________________________________________________________________________ (please print name/title) Signature: _____________________________________________________________________ Date: ________________________ Email: ______________________________________________________Contact Number: _________________________________ (IGB-12/19/19)
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Business Entity Disclosure - ILLINOIS GAMING BOARD
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ILLINOIS GAMING BOARD 160 N. LaSalle Street, Suite 300
Chicago, Illinois 60601-3103
ILLINOIS GAMBLING ACT & SPORTS WAGERING ACTBUSINESS ENTITY DISCLOSURE FORM
Name of Business Entity:
Doing Business As: (an assumed name must be registered with the Secretary of State)
Business Entity’s Position/Relationship to Applicant/Licensee (check all that apply)
Shareholder Shareholder of Parent or Subsidiary
Partner Other
LLC Member
*If Applicant does not hold a FEIN number, state the proposed date for obtaining such number and the Internal Revenue Service District where
federal tax filings will occur.**Depending on the nature of its business, the Business Entity may be required to register with the Department of Revenue and pay certain taxes. To
inquire as to the applicability of these registration requirements, contact the Department of Revenue (Central Registration Division) at 217-785-2889.
INSTRUCTIONS FOR THE ILLINOIS GAMBLING ACT & SPORTS WAGERING ACTBUSINESS ENTITY DISCLOSURE FORM
WARNING
BY FILING THIS FORM, YOU ACCEPT ANY RISK OF ADVERSE PUBLIC NOTICE,
EMBARRASSMENT, CRITICISM, OR OTHER ACTION, OR FINANCIAL LOSS WHICH MAY
RESULT FROM ACTION TAKEN OR NOT TAKEN WITH RESPECT TO THE FORM AND ANY
LICENSE APPLICATION, AND EXPRESSLY WAIVE ANY CLAIM FOR DAMAGES AS A RESULT
THEREOF. INFORMATION NOT REQUESTED IN THIS FORM OR IN ADDITION TO THAT
PROVIDED IN RESPONSE TO THIS FORM MAY BE REQUESTED.
Read the entire Form before responding to the questions.
The total cost of the investigation conducted pursuant to this Application shall be borne by the licensee through whom the Application will be submitted.
This form is an official document. You should respond to the questions contained herein to the Best of your
Knowledge after substantial inquiry. Do not misstate or omit any material fact(s) as each statement made herein
is subject to verification. ANY misrepresentation, failure to reveal information or omission is grounds for
denial of a license application or a finding of unsuitability requiring economic disassociation. “A person
who knowingly makes a false statement on an application is guilty of a Class A misdemeanor.” 230 ILCS
10/1 et seq.
You are under a continuing duty to disclose promptly any changes in the information provided in this form and
additional information and materials submitted to the Illinois Gaming Board. The duty to make such additional
disclosures shall continue throughout any period of licensure granted by the Illinois Gaming Board
associated with this Illinois Gambling Act and Sports Wagering Act Business Entity Disclosure Form.
Type or print the answers to questions in black ink. If a question does not apply to you, so state with “N/A.” If
space available is insufficient, continue on a separate sheet of paper and precede each answer by labeling
the section to which it is responsive. An authorized agent must initial each page, as provided in the top right
hand corner. By placing such initials on each page, the Business Entity attests to the accuracy and
completeness of the information contained on that page.
The male pronoun when used herein shall include the masculine, feminine and neuter as well as the plural, as appropriate.
As used in this disclosure form, the term "applicant" refers to the business entity submitting the disclosure form.
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(IGB-12/19/19) 3
A. FORMS AND DOCUMENTS
Applicant must submit the following Forms in an electronic format and all other required items to the licensee. Thereafter, the licensee shall submit the information to the Board. All copies must be labeled with Applicant's name:
2. Individual Key Person Personal Disclosure Form for each Key Person of the Business Entity who is also a Key Person of the Applicant/Licensee based upon that individual’s ownership interest, ability to control, or exercise significant influence over the management, assets, or operating policies of the Applicant or Licensee. The Board may require Applicant to submit this Form for other Individuals.
3. Schedule of Exhibits.
4. Applicant's Request to Release Information.
5. Release of All Claims.
6. Affidavit of Full Disclosure.
7. Verification.
8. IRS Account Transcripts for the last five years.
9. Complete copies of Federal and State tax returns for the last three years.
Send an electronic copy of the form and additional items to:
Illinois Gaming Board Attn: Licensing Unit
160 N. Lasalle St. Suite 300 Chicago, Illinois 60601-3103
Initials _______
(IGB-12/19/19) 4
B. DEFINITIONS
For the purposes of this Application, the following terms shall have the following meanings:
Act: The Illinois Gambling Act or Sports Wagering Act
Affiliate: An affiliate of an entity is a person that directly, or indirectly through one or more intermediaries, controls, or is controlled
by, or is under common control with, such entity.
Applicant: Any Individual or Business Entity, including any predecessor business entity, who directly or indirectly has submitted an
Owner’s/Organization Gaming License Application, Business Entity Disclosure Form, Individual Key Person Personal Disclosure
Form, Occupational License Level 1Application, Institutional Investor Disclosure Form, or Trust Identification and Disclosure Form.
Application: All material submitted, including the Instructions, Definitions, Forms and other documents issued and/or requested by
the Board, comprising Applicant's Owner’s/Organization Gaming License Application Form.
Attributed Interest: A direct or indirect interest in an Applicant deemed to be held by an Individual not through the Individual's
actual holdings but either through the holdings of the Individual's relatives or through a third party or parties on behalf of the
Individual pursuant to a plan, arrangement or agreement.
Bank: (A) A banking institution organized under the laws of the United States or any other country or jurisdiction, (B) a member bank
of the Federal Reserve System, (C) any other banking institution or trust company, whether incorporated or not, doing business under
the laws of any State or of the United States, a substantial portion of the business of which consists of receiving deposits or exercising
fiduciary powers similar to those permitted to national banks under the authority of the Comptroller of the Currency, and which is
supervised and examined by State or Federal authority having supervision over banks, and which is not operated for the purpose of
evading the provisions of this title, and (D) a receiver, conservator or other liquidating agent of any institution or firm included in
clauses (A), (B) or (C) of this paragraph.
Beneficial Interest: A right, interest, benefit or advantage that a person enjoys from a property or trust, resulting from a contract or
agreement, without actual ownership or control of the property.
Best of Knowledge: Applicant's knowledge after substantial inquiry.
Board: The Illinois Gaming Board.
Business Entity or Entity: A partnership, corporation, unincorporated association or group, firm, limited liability company,
partnership for shares, trust, sole proprietorship or other business enterprise.
Casino: A facility at which lawful gambling is authorized as provided in the Illinois Gambling Act.
Compensation: Anything of value, including without limitation salary, wages, commissions, tips, gratuities, fees, bonuses, stock
options, warrants and distributions from S corporations, in any form, including cash, securities, real property and tangible and
intangible personal property.
Contingent Liability: Any obligation, indebtedness or claim, the amount of which cannot be definitely ascertained until the
occurrence or nonoccurrence of some future event.
Control: The possession, direct or indirect, of the power to direct or cause the direction of the management, operation or policies of an
Individual or Business Entity, whether through the ownership of voting securities, by contract, or otherwise.
Debt Instrument: Any bond, loan, mortgage, trust deed, note, debenture, subordination, guaranty, letter of credit, security agreement,
surety agreement, pledge, chattel mortgage or other form of indebtedness.
Dependent: Any Individual who received over half of his support in a calendar year from any other Individual.
Docksite: The location where a Riverboat Gaming Operation conducts gambling operations pursuant to an Owner’s License or where
a Riverboat moors for the purpose of embarking passengers for and disembarking passengers from a Riverboat Gaming Operation.
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(IGB-12/19/19) 5
Due Diligence: A thorough review of public and private source information that is conducted pursuant to a detailed investigative plan
on the identity, background experience, credentials, licensing, financial stability, and other factors related to a Person’s ability to
perform contractual obligations or otherwise meet the requirements for suitability and licensing in the State of Illinois.
FEIN: Federal Employee Identification Number.
Felony: A criminal offense for which a sentence of imprisonment for one year or more may be imposed under the laws of any
jurisdiction.
Financial Statement: Any balance sheet, income statement, profit and loss statement, statement of cash flow, and sources and uses of
funds statement.
Game: A gambling activity which is played for money, property, or anything of value, including without limitation those played with
cards, Chips, Tokens, Vouchers, dice, implements, or electronic, electrical, or mechanical devices or machines.
Gaming: The dealing, operating, carrying on, conducting, maintaining or exposing for play of any Game.
Gaming-related: Anything related to the dealing, operating, carrying on, conducting, maintaining or exposing for play of any game.
Gaming Equipment/Supplies: A machine, mechanism, device or implement which is integral to the operation of a Game or affects
the result of a Game by determining win or loss, including without limitation: electronic, electrical, or mechanical devices or machines;
cards or dice; layouts for Live Gaming Devices; any representative of value used with any Game, including without limitation chips,
tokens, or electronic cards; Voucher Systems; Voucher Printers; Voucher Validation Terminals; Computer Monitoring Systems; and
hardware and software related to any item described herein.
Gaming Operation: The Applicant for a Casino/Riverboat or Organization Gaming License, Owner licensees, Organization Gaming
licensees, Gaming Operations Manager, or, as the context requires, the conduct of Gaming and all related activities, including without
limitation the purveying of food, beverages, parking, retail goods and services, and transportation, at a Casino/Riverboat or
Organization Gaming facility and at its Support Facilities.
Gaming Operations Manager: An Individual or Business Entity other than the holder of an Owner’s License or an Organization
Gaming License who has the ultimate responsibility to manage, direct or administer the conduct of Gaming.
Immediate Family: Spouse (other than a spouse who is legally separated from the Individual under a decree of divorce or separate
maintenance), parents, grandparents, siblings, children and grandchildren, step-children, whether by blood, marriage, adoption or
natural relationship.
Indirect Interest: An interest in a Business Entity that is deemed to be held by an Applicant or holder of an Owner’s License or an
Organization Gaming License not through the Applicant’s or holder's actual holdings in the Business Entity, but through the
Applicant’s or holder's holdings in other Business Entities.
Individual: Any natural person.
Institutional Investor: A "qualified institutional buyer" as defined by Securities and Exchange Commission Rule 144A (17 CFR
230.144A) under the Securities Act of 1933, as amended.
Internal Control System: Proprietary internal procedures and administration and accounting controls designed by the holder of an
Owner’s License or an Organization Gaming License for the purpose of exercising control over the Riverboat Gaming Operation or
Organization Gaming Operation.
Junketeer: An Individual or business entity that facilitates a patron’s participation in gaming at a Riverboat Gaming Operation and is
compensated, not as an employee but as an independent contractor, by that Operation based upon how much the patron actually wagers
or loses.
Key Person: An Individual or Business Entity identified by the Board under Section 3000.222 of the Board’s Adopted Rules as
subject to regulatory approval as a Person able to control, or exercise significant influence over, the management, assets, or operating
policies of an Owner, Organization Gaming, or Supplier Applicant or Licensee.
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Material Litigation: Pending or threatened litigation and resolved lawsuits, administrative actions, unsatisfied judgments, decrees,
restraining orders, injunctive orders, excluding personal injury litigation resolved for or seeking less than $1,000,000.
Nominee: Any Individual or Business Entity that holds as owner of record the legal title to tangible or an intangible personality or real
property, including without limitation any stock, bond, debenture, note, investment contract or real estate on behalf of another
Individual or Business Entity, and as such is designated and authorized to act on his or its behalf with respect to such property.
Ownership Interest: Includes, but is not limited to, direct, indirect, beneficial or attributed interest, or holder of stock options,
warrants or stock appreciation rights, or holder of any beneficial ownership interest in the Applicant for or holder of an Owner’s
License, an Organization Gaming License.
Organization Gaming License: A license issued by the Illinois Gaming Board under Section 7.7 of the Illinois Gambling Act
authorizing gaming pursuant to that section at an organization gaming facility.
Owner’s License: A license issued by the Illinois Gaming Board to conduct riverboat or a casino gambling operation, but does not
include an organization gaming license.
Parent Company: A "parent company" of a specified person is an affiliate controlling such person directly, or indirectly through one
or more intermediaries.
Pecuniary: Refers to something paid or given in money, or a monetary interest in something.
Predecessor Company: A Business Entity which no longer exists in its original form but whose assets in substantial part have been
acquired by another Business Entity or which had undergone certain internal changes, such as those of identity, form, or capital
structure.
Person: "Person" includes both individuals and Business Entities.
Privately Held Company: A company that is not Publicly Held.
Public Official: An Individual who is elected to, is an officer of or employed by any federal or state office or political subdivision,
pursuant to federal or state law, or who is appointed to an office which is established under and the qualifications and duties of which
are prescribed by such federal or state law to discharge a public duty.
Publicly Held Company: A company that has filed a registration statement with the Securities and Exchange Commission.
Registered Agent: Any Individual or Business Entity against whom service of process may be made on behalf of any Business Entity
or that is designated as such by any articles of incorporation or other corporate filings in any state.
Related Party: An Individual or Business Entity having a pecuniary interest in a Business Entity which is not a Publicly Held
Company; a holder of more than 5% of the outstanding shares of a Publicly Held Company; a Key Person of a Business Entity; an
Affiliate of a Business Entity; a Relative of an Individual having a pecuniary interest in a Business Entity which is not a Publicly Held
Company; a Relative of a holder of more than 5% of the outstanding shares of a corporation which is a Publicly Held Company; a
Relative of a Key Person of a Business Entity; a Relative of an Affiliate of a Business Entity; a trust for the benefit of or managed by a
Business Entity or a Key Person thereof; or any other Individual or Business Entity who is able to control or significantly influence the
management or operating policies of a Business Entity.
I, __________________________________________________________________, being the duly authorized (Officer)
_______________________ of _______________________________________________, being (Office) (Name of Applicant)
first duly sworn upon oath or affirmation depose and state:
1. On behalf of Applicant I submit this Application.
2. I swear (or affirm) and certify that the information contained in this application is true, complete
and accurate to the best of my knowledge and belief.
Applicant: _________________________________
By: ________________________________ (Print Name)
____________________________________ (Signature)
Its: _________________________________ (Title)
SUBSCRIBED and SWORN to before me this
_______ day of __________________, 20_____.
________________________________________
Notary Public
Notary Public in and for the
County of __________________
State of ____________________
(IGB-12/19/19)
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(IGB-12/19/19) 28
IMPORTANT – To Prevent Delays in Processing
Please Read and Follow These Instructions:
Instructions for 4506-T Request for Transcript of Tax Return
Tax transcripts of your business tax return are required for the previous four years by the Illinois Gaming Board
in order to complete your application.
Complete Form 4506-T Request for Transcript of Tax Return and fax the form to the IRS. This form is available
from the IRS at http://www.irs.gov/pub/irs-pdf/f4506t.pdf . Please follow the following instructions when
completing the form:
o Parts 1a & 1b: Enter Entity Name listed on Business Tax Return and FEIN.
o Parts 2a and 2b: Fill in Part 2a and 2b if any of the requested tax years include a joint filer.
o Part 3: Enter Entity’s Current Address.
o Part 4: Complete this section if any of the requested tax years were filed using a different address.
o Part 6: Enter the tax form number (income tax 1120, 1120S, or 1065); (unemployment tax 940): and (payroll tax quarterly 941s). A separate 4506-T is required for each type of form.
o Part 6b: The Illinois Gaming Board requires Account Transcripts for Forms 1120, 1041, 940, and 941 and Record of Account Transcripts for Form1065. Check box 6b.
o Part 6c: The Illinois Gaming Board requires Record of Account Transcripts for Form 1065. Check box 6c.
o Part 9: Enter the ending date of the last four years in mm/dd/yyyy format for the income tax and unemployment tax and each quarter ending for the four quarters for 941s. Note, for the 941 transcripts a separate 4506-T form will need to be prepared for each of the four years requested with each of the quarters listed for the corresponding year.
o SIGN and DATE the Form – Note: Must be signed by the ‘Responsible Party’ as listed on the SS-4 Application Form or by the subsequent individual designated per Form 8822-B.
Any amendments or changes to the form which have been crossed-out will need to be initialed and dated.
Once you receive your tax transcripts, please mail or fax the transcripts to: