000016033 Application Package

8/12/2019 000016033 Application Package

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Georgia Lottery Corporation

Verification of Lawful Presence Within the United StatesO.C.G.A. 50-36-1(f)(1) Affidavit

a)Legal Business Name: _________________________________________________________

b) By executing this affidavit under oath, as an applicant for Coin Operated Amusement

Machine (COAM) License Number: ________________ as referenced inO.C.G.A. 50-36-1, from the Georgia Lottery Corporation, the undersigned applicant

verifies one of the following with respect to my application for a COAM License(s):

c) I am a United States citizen.

I am a legal permanent resident of the United States.

I am a qualified alien or non-immigrant under the Federal Immigration and

and Nationality Act with an alien number issued by the Department of

Homeland Security or other federal immigration agency.

d) My alien number issued by the Department of Homeland Security or other federal

immigration agency is: (A#)____________________.

The undersigned applicant also hereby verifies that he or she is 18 years of age or older

and has provided at least one secure and verifiable document, as required by O.C.G.A.

50-36-1(f)(1)(A), with this affidavit.

e) The secure and verifiable document provided with this affidavit can best be classified as:

_____________________________________________________________________.

In making the above representation under oath, I understand that any person who

knowingly and willfully makes a false, fictitious, or fraudulent statement orrepresentation in an affidavit shall be guilty of a violation of O.C.G.A. 16-10-20, and

face criminal penalties as allowed by such criminal statute.

Executed in _________________________ (city), ________________(state).

____________________________________Signature of Applicant

____________________________________

Printed Name of ApplicantSUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

______DAY OF ____________, 20___

_________________________

NOTARY PUBLICMy Commission Expires:

FUN TIME AMUSEMENT GROUP INC

000016033


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Required Documents for COAM License Application

(Applicable only to Class B Masters and Locations with Class B Machines)

Document Checklist

All applicants for Coin Operated Amusement Machine (COAM) Class B Masters and Locations

with Class B Machines are required to complete and submit the documents listed below. Please

utilize these instructions to prepare and mail the documents required to complete your COAMLicense application.

These documents must be submitted by each owner(top 10 primary owners, officers, partners,members, and shareholders):

1. Coin Operated Amusement Machine Application: review the Part 1 BusinessInformation page and each owners specific Part 2 - Personal Information page of the

attached application and sign on the designated signature line. Each owners signedPart2- Personal Informationpage must benotarized.

2. Affidavit: A signed and sworn (notarized) Verification of Lawful Presence Within theUnited States Affidavit verifying each owners lawful presence in the United States.

How to Fill Out the Affidavit:

a) Legal Business Name Prefilled as entered in the COAM website.b) License Number Prefilled by the COAM website.c) Citizenship Status Check any one of the three options that best describes your

citizenship status.

d) If you are a qualified alien or non-immigrant under the Federal Immigration andNationality Act, provide your alien number issued by the Department of Homeland

Security or other federal immigration agency.

e) Provide the type of Secure and Verifiable Document that you will submit with youraffidavit. Attached is a complete list of acceptable Secure and Verifiable Documents.

3. Secure and Verifiable Document: A legible front and back copy of each ownersapplicable Secure and Verifiable Document. Attached is a complete list of acceptable

Secure and Verifiable Documents.

Purpose of the Affidavit: Georgia Law (O.C.G.A. 50-36-1, et seq.) requires the GLC to verify the

lawful presence within the United States of all applicants for licenses, and, when necessary, utilize

the Systematic Alien Verification for Entitlements (SAVE) Program to confirm an applicants lawful

presence in the United States. The SAVE Program is an intergovernmental information-sharing

initiative designed to assist Federal, State government agencies and non-governmental agencies,

such as licensing bureaus, in determining an individuals immigration status. The information

provided by SAVE will ensure that only entitled applicants will be granted the license for which they

applied. SAVE only provides the immigration status of these individuals and does not make

determinations or recommendations regarding a non-citizens eligibility for the license.


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Page 2

Required License Application Documents

4. Photo Identification: Attach a copy of one of the following forms of photo identification tothe printed version of their application:

Drivers License Identification Card issued by Georgia or another state U.S. Armed Forces Identification Card U.S. Passport or Resident Alien Card

5. Explanations: Eachapplicant (primary top 10) that answered yes to any of the questionslisted on the Part 2 - Personal Information page of their application, should provide

explanations on a separate sheet of paper and attach to the printed version of their

application.

6. Proof of Divested Interest: If a Master Class B applicant had interests in any businessoperating as a COAM manufacturer, distributor, location owner or location operator withinthe past 5 years and divested their interest in the location, written proof of the closing must

be provided (to include date of sale, name, address and telephone number of the purchaser).

Copies of this written proof must be attached to their printed version of the application.

Note: Your application cannot be renewed or approved until all the documents are completed

and returned to the Georgia Lottery.

For Class B Masters only: If a Verification of Lawful Presence Within the United States

Affidavit and Secure and Verifiable Document have already been mailed to the Georgia

Lottery for each owner, it is not necessary to re-submit.

Mail the documents listed above for each of the primary (top ten) owners, officers, partners,

members and shareholders to the following address:

Georgia Lottery Corporation

COAM Department

P.O. Box 56927

Atlanta, GA 30343


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Acceptable Secure and Verifiable DocumentsUnder O.C.G.A. 50-36-2

An unexpired United States passport or passport card An unexpired United States military identification card An unexpired Drivers license or Identification Card issued by one of the United States, District of

Columbia, Commonwealth of Puerto Rico, Guam, Commonwealth of the Northern Marianas Islands,

United States Virgin Island, American Samoa, or Swain Islands, provided that it contains a

photograph of the bearer or lists sufficient identifying information regarding the bearer, such as

name, date of birth, gender, height, eye color, and address to enable the identification of the bearer.

An unexpired Tribal identification card of a federally recognized Native American tribe, providedthat it contains a photograph of the bearer or lists sufficient identifying information regarding the

bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification

of the bearer. A listing of federally recognized Native American tribes may be found at:

http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/ ind ex.htm

An unexpired United States Permanent Resident Card or Alien Registration Receipt Card An unexpired Employment Authorization Document that contains a photograph of the bearer An unexpired Passport issued by a foreign government, provided that such passport is accompanied

by a United States Department of Homeland Security (DHS) Form I-94, DHS Form I-94A, DHS

Form I-94W, or other federal from specifying an individuals lawful immigration status or other

proof of lawful presence under federal immigration law.

An unexpired Merchant Mariner Document or Merchant Mariner Credential issued by the UnitedStates Coast Guard.

An unexpired Free and Secure Trade (FAST) card. An unexpired NEXUS card. An unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card. An unexpired Drivers license issued by a Canadian government authority.

Certificate of Citizenship issued by the United States Department of Citizenship and ImmigrationServices (USCIS) (Form N-550 or Form N-570)

Certificate of Naturalization issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-550 or Form N-570) Certification of Report of Birth issued by the United States Department of State (Form DS-1350) Certification of Birth Abroad issued by the United States Department of State (Form FS-545) Consular Report of Birth Abroad issued by the United States Department of State (Form FS-240) An original or certified copy of a birth certificate issued by a State, county, municipal authority, or

territory of the United States bearing an official seal

In addition to the documents listed herein, if, in administering a public benefit or program, an agencyis required by federal law to accept a document or other form of identification for proofof or documentation of identity, that document or other form of identification will be deemed asecure and verifiable document solely for that particular program or administration of that particular

public benefit.


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11. List each owner, shareholder, member and ofcer of the Business. EACH LISTED INDIVIDUAL MUST COMPLETE PART 2 OF THIS FORM.

12. (OPTIONAL) Is Business Ownership more than 50% of a minority race? Yes No

If Yes, Specify: African American Native American Asian Hispanic Other (specify):

13. Business Contacts: Name Title/Function Cell Phone #

a.

b.

14. Has the business entity had a gambling license in any state or jurisdication? Yes No IfYes, provide the following:

State or Jurisdication that issued license: What year(s) the license was held:

a. Name: % of Ownership:

b. Name: % of Ownership:

c. Name: % of Ownership:

d. Name: % of Ownership:

e. Name: % of Ownership:

7. Georgia Alcohol License Number: 8. Georgia Sales Tax Number:

4. Business Address:

Address Line 1:

Address Line 2:

City: State: Zip Code:

County: Fax Number:

Business Telephone Number:6. Georgia State Tax Identier Number:

Coin Operated Amusement Machine Application

GEORGIA LOTTERY CORPORATION P.O. Box 56927 Atlanta, GA 30343

1-800-746-8546 - OPTION #4 - Retailer Contracts AdministrationPART 1- Business Information

Revised May 201

CLASS B MASTER LICENSE ID#:

1. Corporate or legal name:

2. Type of Ownership: Sole Proprietor Partnership Corporation Non-Prot

LLC (Corporation) LLC (Partnership) Other(specify):

3. Store Name or DBA Name:

5. Mailing Address:

Address Line 1:

Address Line 2:


9. Federal Employer Identication Number(EIN)/SS Number: 10. Withholding Tax Number:

15. Who maintains the business entity's nancial and business records?

16. Where are these nancial and business records kept? Address Line 1:

Address Line 2: City: State: Zip Code:

17. Who prepares the business entity's tax returns and governmental registrations and lings?

18. Has the business entity entered into a lease or agreement with a manufacturer or distributor for the licensing of software, hardware, or any

part of Class B machines? Yes No

19. List the names of all manufacturers, suppliers, and distributors of the COAM machines, parts, hardware and software?

20. Is this business a Georgia Lottery retailer? Yes No If Yes, enter 6 digit retailer number:

21. Business Information Prepared by:

Name Title Date

f. Name: % of Ownership:

g. Name: % of Ownership:

h. Name: % of Ownership:

i. Name: % of Ownership:

j. Name: % of Ownership:

000016033



266 my street 266 my street

Atlanta GA 30308

FULTON

(404)2073333

Atlanta GA 30308

20219032102

111111111

Kyi Lee 100

john bob Big Bob (404)222-3366

kyi

253 over ln

Atlanta GA 30308

tod

kyi CEO 05/20/2014


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13. Place of Birth: City:

State: Country:

14. Height: 15. Weight: 16. Hair Color: 17. Eye Color:

18. Do you reside in the same household as any ofcer or employee of the Georgia Lottery Corporation? Yes No

19. Are you a vendor, employee or agent of any vendor of the Georgia Lottery Corporation? Yes No

20. Have you been convicted of a criminal offense related to the security or integrity of the lottery in this or any other jurisdiction? Yes No

21. Have you been convicted of any illegal gambling activity, false statements, false swearing or perjury in this or any other jurisdiction

or convicted of any crime punishable by more than one year of imprisonment or a ne of more than $1,000.00 or both? Yes No

22. Are you delinquent in taxes, fees or other obligations owed to the State of Georgia? Yes No

23. Have you led bankruptcy in the last seven (7) years? Yes No

24. Are you related to a COAM location owner, operator, distributer, or manufacturer? Yes No

Note: If you answered Yes to any of the above questions(18through24) please explain on a separate sheet and attach to this application.

25. Have you had a gambling license in any state or jurisdiction?........... ............ ............. ............ ............ ............ ............ .......... Yes No

If yes provide the following: State or Jurisdiction that issued the license: What year(s) the license was held:

26. Have you had interests in any business operating as a COAM manufacturer, distributor, location owner, or location

operator within the last 5 years?............ ............ ............. ............ ............ ............ ............ ............ ............ ............ ............ ...... Yes No

If yes, did you divest your interest in the location?.......... ............ ............ ............ ............ ............ ............ ............ ............ ...... Yes No

If yes, provide written proof of closing, which should include date of sale, name, address and telephone number of purchaser.

Attach to the printed application and mail to the Georgia Lottery Corporation.

27. Have you entered into a lease or agreement with a manufacturer or distributor for the licensing of software, hardware,

or any part of Class B machines? Yes No

28. Personal Information Prepared by:

Name Title Date

1. First, Middle & Last Name of Owner or Principal: 2. M or F: 3. Title: 4. Race: 5. Date of Birth:

6. % of Ownership: 7. E-mail: 8. Primary Phone Number: 9. Alternate Phone Number: 10. Social Security Number:

11. Home Address:

Address line 1:

Address line 2:


Signature Print Name Date

Revised May 201

CLASS B MASTER LICENSE ID#:PART 2 - Personal Information

CONSENT AND AUTHORIZATION FOR RELEASE OF PERSONAL BACKGROUND INFORMATION:I hereby certify that the information contained on this form or otherwise submitted by me to the Georgia Lottery Corporation (GLC) in connection with this Applicantsapplication to become a Bona Fide Coin Operated Amusement Machine (COAM) licensee is true and correct in every respect. Specically, I certify that I havreviewed both the Applicants Business Information Page(s) as submitted, and my own Owner Information Pages for this application, and I certify that the informationcontained therein is true and correct in every respect. I understand, agree and consent that GLC may make any and all investigations of my background in ordeto satisfy the GLC requirements for qualication of the Applicant as a COAM Licensee, which investigations may include, without limitation, criminal history recorinformation, credit history records, tax records, public records and other ofcial records, and the investigation generally of any other matter relating to both me anthe Applicant being a COAM Licensee. As a potential COAM Licensee or a current COAM Licensee, licensed by the GLC, or as an owner of same, I am requireto furnish certain information for use in determining my qualications. I hereby authorize GLC to request a credit report, conduct a criminal background investigationor conduct any other investigation as may be necessary to process my COAM Licensee Application. I authorize GLC to share any such information, privilegedcondential or otherwise, necessary to consider the application to become a COAM Licensee. I further consent to allow GLC to use and share such information in anand all manners consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out of the relationshipbetween the Applicant and GLC. A photocopy of this release will be valid as an original thereof, even though said photocopy does not contain an original writing omy signature. This release will expire upon the nal termination of the Applicants COAM License obligations to the GLC. I further understand and acknowledge thaproviding inaccurate or misleading information is grounds for rejection of this application and suspension or cancellation of the COAM License and may subject the

Applicant and me to the penalties set forth in the Georgia Lottery for Education Act, O.C.G.A. 50-27-1, et seq.

a.

b.

c.

d.

Coin Operated Amusement Machine Application

GEORGIA LOTTERY CORPORATION P.O. Box 56927 Atlanta, GA 30343

1-800-746-8546 - OPTION #4 - Retailer Contracts AdministrationThis information must be completed for each of the primary(top 10) owners, partners, and shareholders of the business.

STATE OF: COUNTY OF:

SWORN TO AND SUBSCRIBED BEFORE ME ON THIS DAY OF (MONTH) (YEAR)

Notary Public Seal and Signature: My Commission Expires:

Personal Identification (ID) is required to be presented to and verified by Notary Public. Type of ID: ID Number:

12. List all other names you have used, including nicknames, surname

other than your true name, or if female, furnish your maiden name:

First Middle Last

000016033

Kyi Lee Male CEO White 5/16/1979

100 [email protected] (404)207-3966 416223366

123 elm st

Mobile AL 36693

Mobile

Al Mobile

6 180 black black

Kyi CEO 05/20/2014

000016033 Application Package

Documents

Transcript of 000016033 Application Package