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The Florida Lottery Dol 129 form is a crucial document for those interested in becoming a lottery retailer in the state of Florida. This form serves multiple purposes, including the application process for new retailers, changes in ownership, and updates on store locations. Applicants must provide detailed information about their business, including the corporate name, store name, contact details, and taxpayer identification numbers. A non-refundable application fee is required, with varying amounts based on the type of application submitted. Additionally, a background investigation is conducted on all applicants, which may include fingerprinting. Retailers may also need to secure a bond or other forms of security if deemed necessary during the investigation. The form ensures compliance with state regulations and includes sections to disclose any potential conflicts of interest, such as relationships with current Florida Lottery employees. Completing this form accurately and thoroughly is essential for a successful application process.

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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)

Form Specifications

Fact Name Details
Application Purpose The DOL-129 form is used for retailers applying to sell Florida Lottery tickets.
Application Fees Fees include $100 for an initial application, $25 for an additional location, and $10 for a change of location.
Background Investigation All applicants undergo a background investigation, which may include fingerprinting.
Bond Requirement Applicants may need to post a bond or other security based on the background investigation results.
Public Disclosure Information in the application is public and available for inspection under Florida law.
Governing Law The application is governed by Section 24.112, Florida Statutes, and the Federal Privacy Act.

Florida Lottery Dol 129: Usage Guidelines

Filling out the Florida Lottery DOL 129 form is an important step in becoming a retailer. After completing the form, you will need to submit it along with the required fees and any additional documentation. The Florida Lottery will review your application and conduct background checks as necessary.

  1. Obtain the Form: Download the DOL 129 form from the Florida Lottery website or obtain a physical copy from a lottery office.
  2. Fill Out Retailer Information: Write your Florida Lottery ID number and Chain number at the top of the form. Indicate the type of application you are submitting.
  3. Complete Business Information: In Section 1, provide your business's legal name, store name, contact details, and taxpayer identification numbers. Be sure to include your Florida sales tax number and any relevant licenses.
  4. Provide Officer/Owner Information: In Section 2, list all owners and corporate officers. Include their contact information, birthdates, and ownership percentages.
  5. Answer Background Questions: Respond to the questions regarding criminal history and previous lottery retailer status. Be honest, as this information is crucial for your application.
  6. Certification: Read and sign the certification statement. This confirms that all information is accurate and that you understand the responsibilities associated with being a retailer.
  7. Notarization: Have the form notarized. This step is necessary for the application to be valid.
  8. Submit the Application: Send the completed form along with the non-refundable application fee to the Florida Lottery at the address provided on the form.

Your Questions, Answered

What is the Florida Lottery DOL 129 form?

The Florida Lottery DOL 129 form is an application for businesses that wish to become authorized retailers of lottery tickets in Florida. This form collects essential information about the business, its owners, and any relevant background details necessary for the application process.

What fees are associated with the DOL 129 application?

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

Is a background check required for all applicants?

Yes, all applicants must undergo a background investigation, which may include fingerprinting. This process ensures that the individuals involved in the business meet the necessary qualifications to operate as a lottery retailer. If the investigation reveals any concerns, the Florida Lottery may require the applicant to post a bond or other security.

What information do I need to provide on the DOL 129 form?

The form requires various details, including the legal name of the business, store name, contact information, and taxpayer identification number. You will also need to disclose the owners and officers of the business, their contact details, and any relevant criminal history. It’s crucial to provide accurate and complete information to avoid delays or rejection of your application.

Can I apply for multiple locations with one DOL 129 form?

No, each location requires a separate application. However, if you are adding an additional store location, you can indicate that on the form and pay the associated fee of $25. Each application must be filled out completely and submitted individually to ensure proper processing.

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. The Florida Lottery reserves the right to verify all information provided, and any discrepancies may have serious consequences for your ability to operate as a retailer.

How is my personal information protected when I submit the DOL 129 form?

Your information is subject to the Federal Privacy Act, which requires that your Social Security number and other personal details be kept confidential. However, some information may be open to public inspection as part of the application process. The Florida Lottery uses this information primarily for tax reporting and background investigation purposes.

Common mistakes

  1. Failing to provide a Florida Lottery ID number. This number is essential for processing the application.

  2. Not selecting the correct application type. Applicants must check the appropriate box to indicate whether they are submitting an initial application, a change of location, or another type.

  3. Omitting business information. Complete details such as the corporate name, store name, and address must be accurately filled out.

  4. Providing an incorrect taxpayer identification number. It is crucial to list the correct number used for filing business income taxes.

  5. Neglecting to disclose any criminal history. All relevant information regarding felony convictions or gambling offenses must be included.

  6. Not listing all owners or corporate officers. Complete information for all individuals with a significant interest in the business is necessary.

  7. Forgetting to include the contact information of the landlord if the retailer does not own the location. This information is vital for approval.

  8. Failing to sign and date the application. An unsigned form will lead to delays or rejection of the application.

Documents used along the form

The Florida Lottery Dol 129 form is an essential document for individuals or businesses wishing to become authorized retailers of lottery products in Florida. Alongside this form, several other documents are typically required to ensure compliance with state regulations and to facilitate the application process. Below is a brief overview of four such documents that are often used in conjunction with the Dol 129 form.

  • Background Check Authorization Form: This form is necessary for conducting a thorough background investigation of the applicant. It typically requires the applicant to provide personal information, including social security numbers, to allow the Florida Lottery to verify the applicant's identity and check for any criminal history that may affect their eligibility to sell lottery tickets.
  • Certificate of Authority: This document is issued by the Florida Department of State and confirms that a business is legally registered to operate in Florida. It serves as proof that the business complies with state laws and regulations, which is crucial for obtaining a lottery retailer license.
  • Sales Tax Registration Certificate: Retailers must provide proof that they are registered to collect sales tax in Florida. This certificate verifies that the business is in good standing with the Florida Department of Revenue, ensuring that it is authorized to operate and collect taxes on sales, including lottery tickets.
  • Lease Agreement or Property Ownership Documents: If the retailer does not own the property from which they intend to sell lottery products, a lease agreement must be submitted. This document outlines the terms of the rental agreement and confirms that the landlord permits the installation of necessary lottery equipment. If the retailer owns the property, proof of ownership may be required instead.

Each of these documents plays a vital role in the application process for becoming a Florida Lottery retailer. By ensuring that all required forms and supporting documents are accurately completed and submitted, applicants can streamline their chances of a successful application and subsequent approval to sell lottery products.

Similar forms

The Florida Lottery DOL 129 form is similar to several other documents that serve various purposes in business applications and compliance. Below is a list of six documents that share similarities with the DOL 129 form:

  • Business License Application: Like the DOL 129, this document requires detailed information about the business, its owners, and its operations. Both forms often necessitate a background check and may require fees.
  • Retail Sales Tax Registration: This form collects information about the business's tax identification and operational details. It ensures compliance with state tax laws, similar to how the DOL 129 ensures compliance with lottery regulations.
  • Employer Identification Number (EIN) Application: This document is essential for tax purposes and requires information about the business and its owners. Both forms serve to identify the business for regulatory purposes.
  • Alcohol Beverage License Application: This application requires background checks and detailed information about the business and its owners, much like the DOL 129. Both are aimed at ensuring responsible business practices.
  • Franchise Disclosure Document (FDD): The FDD provides information about the franchisor and the franchisee, similar to how the DOL 129 outlines the responsibilities and requirements for lottery retailers.
  • Professional License Application: This document requires detailed personal and business information to ensure that applicants meet specific professional standards, paralleling the background checks and compliance measures in the DOL 129.

Dos and Don'ts

When filling out the Florida Lottery DOL 129 form, careful attention to detail is essential. Here are ten important dos and don'ts to consider.

  • Do ensure all information is accurate and complete before submission.
  • Do print or type all responses clearly to avoid misinterpretation.
  • Do include the correct non-refundable application fee as specified.
  • Do provide a valid taxpayer identification number, whether it’s a Social Security Number or Federal Employer Identification Number.
  • Do disclose any criminal history truthfully, as it may affect your application.
  • Don't leave any required fields blank; incomplete forms may be rejected.
  • Don't use abbreviations or shorthand in your answers; clarity is crucial.
  • Don't submit the application without ensuring compliance with accessibility requirements.
  • Don't provide misleading information; this could result in rejection or cancellation of your application.
  • Don't forget to sign the application; an unsigned form is not valid.

Following these guidelines will help facilitate a smoother application process for becoming a Florida Lottery retailer.

Misconceptions

  • Misconception 1: The DOL 129 form is only for new lottery retailers.
  • This form is used for various purposes, including changes of location, ownership, and adding new officers or shareholders. It is not limited to initial applications.

  • Misconception 2: Completing the form guarantees approval to sell lottery tickets.
  • Submitting the DOL 129 form does not automatically guarantee that your application will be approved. A thorough background investigation is conducted, and compliance with all requirements is necessary.

  • Misconception 3: There are no fees associated with the DOL 129 form.
  • Applicants must pay a non-refundable application fee. The fees vary based on the type of application, such as $100 for an initial application and $25 for additional locations.

  • Misconception 4: Only individuals with a clean criminal record can apply.
  • While a clean record is preferred, applicants with past convictions may still apply. Each case is evaluated on its own merits, and the nature of the offense is considered.

  • Misconception 5: The DOL 129 form does not require personal information.
  • The form requires detailed personal information, including Social Security numbers, for all owners and significant stakeholders. This information is essential for background checks.

  • Misconception 6: All information provided on the form remains confidential.
  • Information submitted through the DOL 129 form is subject to public disclosure. It is important for applicants to be aware that their information may be accessible to the public.

  • Misconception 7: You can submit the form electronically without any additional steps.
  • While some parts of the application process may be handled online, certain sections, especially those requiring notarization, must be completed in person. Ensure all steps are followed carefully.

Key takeaways

When filling out and using the Florida Lottery Dol 129 form, keep the following key takeaways in mind:

  • Application Fees: Be prepared to pay a non-refundable application fee. The initial application costs $100, while additional locations cost $25, changes of location are $10, and new officers or shareholders are $25 each.
  • Background Investigation: Each applicant undergoes a background check, which may include fingerprinting. Be aware that certain conditions may require you to post a bond or other security.
  • Accurate Information: Ensure all information is accurate and complete. Providing misleading information can lead to rejection or cancellation of your application.
  • Accessibility Compliance: Confirm that the business location complies with accessibility requirements as outlined in Florida statutes.
  • Ownership Details: List all owners and significant stakeholders. This includes anyone with 10% or more ownership, and all individuals must provide personal information such as birthdate and Social Security number.
  • Public Disclosure: Understand that the information provided in the application is subject to public inspection, so privacy should be considered.
  • Notary Requirement: The application must be signed in the presence of a notary public. Ensure that the notary's signature and seal are properly affixed.

By keeping these points in mind, you can navigate the application process more effectively and enhance your chances of becoming a Florida Lottery retailer.