The Florida Lottery DOL 129 form is an application used by businesses seeking to become authorized retailers of lottery tickets in Florida. This form collects essential information about the business and its owners, and it includes details required for a background investigation. Completing this form accurately is crucial for a smooth application process, so be sure to fill it out carefully by clicking the button below.
The Florida Lottery Dol 129 form serves as a crucial document for individuals or businesses seeking to become authorized retailers of lottery tickets in Florida. This application requires the submission of various details, including the retailer's business information, ownership structure, and compliance with specific legal requirements. Applicants must pay a non-refundable application fee, which varies based on the type of application being submitted, such as an initial application or a change of location. Background checks are mandatory, and applicants may need to undergo fingerprinting. The form also requires information about the business type and tax identification numbers, ensuring that all potential retailers meet the necessary qualifications. Additionally, applicants must disclose any criminal history of owners or officers, as this could impact their eligibility. Understanding the specific requirements and processes outlined in the Dol 129 form is essential for anyone looking to engage in lottery ticket sales in Florida.
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
4
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 a crucial step for those looking to become a retailer. This application requires careful attention to detail to ensure that all necessary information is provided accurately. Once the form is filled out, it will be submitted for review, and a background investigation will follow. Below are the steps to guide you through the process of filling out the form.
Once submitted, the application will undergo a review process. Be prepared for a background investigation, which may include fingerprinting. Ensure that all information is accurate to avoid delays or rejection of your application.
What is the Florida Lottery DOL 129 form?
The Florida Lottery DOL 129 form is an application for retailers who wish to sell lottery tickets in Florida. This form collects essential information about the business and its owners, including background details that may be necessary for a thorough review process. It is important to complete the form accurately to avoid delays in the application process.
What are the fees associated with the DOL 129 form?
There are several fees that applicants must pay when submitting the DOL 129 form. The initial application fee is $100. If you are applying for an additional location, the fee is $25. A change of location costs $10, while adding a new officer, director, or shareholder incurs a fee of $25 each. Remember, these fees are non-refundable and must be paid via check or money order made out to the Florida Lottery.
What information is required in Section 1 of the form?
Section 1 of the DOL 129 form requires detailed business information. This includes the corporate or legal name, store name, contact details, mailing address, and taxpayer identification number. Additionally, you must provide the Florida sales tax number and any applicable alcoholic beverage license number. It is crucial to ensure that all information is accurate and up-to-date.
What background checks are conducted for applicants?
All applicants will undergo a background investigation. This may include fingerprinting to verify identity and assess eligibility. The Florida Lottery may also require applicants to post a bond or other security if deemed necessary during the investigation. This process ensures that only qualified individuals are allowed to sell lottery tickets.
Can I apply for multiple locations with one application?
No, each location requires a separate application. If you wish to add an additional location, you must complete the DOL 129 form for that specific location and pay the applicable fee of $25. Ensure that you provide all required information for each location to avoid complications.
What happens if I provide false information on the application?
Providing inaccurate or misleading information can lead to the rejection of your application or the cancellation of your retailer contract. It is essential to review all details carefully before submission to ensure that everything is correct and truthful.
How can I check the status of my application?
To check the status of your application, you can contact the Florida Lottery directly at (850) 487-7714 or visit their website at flalottery.com. They can provide updates and answer any questions you may have regarding your application process.
What should I do if I have questions while filling out the form?
If you encounter any questions or uncertainties while completing the DOL 129 form, it is advisable to reach out to the Florida Lottery's customer service. They can provide guidance and clarify any aspects of the application process to ensure that you submit a complete and accurate application.
Is there a deadline for submitting the DOL 129 form?
While there is no specific deadline for submitting the DOL 129 form, it is recommended to apply as soon as you are ready. The review and approval process can take time, so submitting your application promptly will help you start selling lottery tickets sooner.
Filling out the Florida Lottery DOL 129 form can be a straightforward process, but mistakes are common and can lead to delays or even rejections. One frequent error occurs when applicants fail to provide accurate contact information. This section is crucial, as it allows the Florida Lottery to reach out for any clarifications or updates regarding the application. Omitting a phone number or providing an incorrect email can result in missed communications, which can be detrimental to the application process.
Another mistake often made is neglecting to check the appropriate application type. The form offers several options, such as "Initial Application" or "Change of Ownership," and selecting the wrong category can create confusion. This oversight not only complicates the review process but may also lead to the application being returned for correction, wasting valuable time.
Applicants sometimes overlook the requirement to disclose all owners and significant shareholders accurately. It’s essential to list everyone who holds a 10% or more interest in the business. Failing to do so may raise red flags during the background investigation. This could lead to the application being denied or delayed as the Lottery seeks to clarify ownership details.
In addition, many people underestimate the importance of the background check questions. Applicants might provide vague or incomplete answers regarding past convictions or gambling offenses. These questions are taken seriously, and any discrepancies can result in rejection. Transparency in this section is key to building trust with the Florida Lottery.
Lastly, some applicants neglect to sign and date the certification section at the end of the form. This step is not merely a formality; it confirms that the information provided is accurate and complete. Without a signature, the application may be considered invalid, leading to unnecessary complications. Taking a moment to ensure all sections are complete and properly signed can save time and frustration in the long run.
When applying to become a Florida Lottery retailer, several additional forms and documents may be required alongside the Florida Lottery DOL 129 form. Each of these documents plays a vital role in ensuring compliance and facilitating the application process.
Gathering these documents will help streamline the application process and ensure compliance with Florida Lottery regulations. Each piece of information is crucial in establishing a trustworthy and responsible retailer relationship.
The Florida Lottery DOL 129 form is a crucial document for those wishing to become lottery retailers in Florida. Several other documents share similarities with this form in terms of purpose and required information. Here’s a list of seven documents that are comparable:
When filling out the Florida Lottery Dol 129 form, it's crucial to approach the task with care and attention to detail. Here are seven essential do's and don'ts to guide you through the process.
By following these guidelines, you can enhance your chances of a smooth application process and avoid common pitfalls that may lead to complications.
Misconception 1: The DOL 129 form is only for new retailers.
This is incorrect. The DOL 129 form can also be used for various purposes, including changes of location, changes in ownership, and updates for new officers or shareholders. It serves multiple functions beyond just initial applications.
Misconception 2: The application fee is refundable.
In reality, the application fee for the DOL 129 form is non-refundable. Whether you are applying for a new location or making changes to an existing one, the fees paid will not be returned if the application is denied or if you decide not to proceed.
Misconception 3: Background checks are optional for applicants.
This is a misunderstanding. All applicants are subject to a background investigation, which may include fingerprinting. This process is mandatory and helps ensure that all retailers meet the necessary qualifications to operate.
Misconception 4: The DOL 129 form is a private document.
On the contrary, the information submitted in the DOL 129 form is subject to public disclosure. This means that the details contained within the application can be inspected by the public, ensuring transparency in the lottery retailer selection process.
Here are some key takeaways regarding the Florida Lottery Dol 129 form:
Completing this form correctly is crucial for a successful application. Ensure all details are accurate and complete to avoid delays or rejections.