La. Admin. Code tit. 42 § III-120

Current through Register Vol. 50, No. 5, May 20, 2024

Section III-120 - Application and Reporting Forms

A. All applicants, licensees, permittees, and persons required to be found suitable shall utilize and complete, as applicable, the most recent version of the following forms.

1. Riverboat

a. Level I, Part A, Suitability Gaming Application, DPSSP 6616, including, but not limited to:

i. Instructions;

ii. Application for Gaming License or Suitability Approval Application, Business Entity Form;

iii. Applicant Information;

iv. Ownership Interest;

v. General Information;

vi. Records/Books Information;

vii. Professional Services Information;

viii. Gaming Information (Miscellaneous);

ix. General Applicant Information;

x. Financial Disclosure Information;

xi. Affidavit of Full Disclosure;

xii. Applicant's Request to Release Information;

xiii. Verification;

xiv. Release of All Claims;

xv. Business Tax Information Authorization Request;

xvi. Federal Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

xvii. Federal Internal Revenue Service Gaming Tax Clearance Certificate;

xviii. State Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

xix. Louisiana Department of Revenue and Taxation Tax Clearance Certificate.

b. Level I, Part B, Personal History and Financial Record Suitability Gaming Application, DPSSP 6617, including, but not limited to:

i. Instructions;

ii. Personal History and Financial Record Suitability Gaming Application;

iii. Personal Information;

iv. Criminal History Information;

v. Civil Litigation Information;

vi. Military Service Data Information;

vii. Employment History Information;

viii. Professional Licenses, etc., Information;

ix. Business Associations Information;

x. Financial Information;

xi. General Information;

xii. Supplemental Page Information;

xiii. Verification;

xiv. Affidavit of Full Disclosure;

xv. Individual's Request to Release Information;

xvi. Release of All Claims;

xvii. Individual Tax Information Authorization Request;

xviii. Louisiana Department of Revenue and Taxation Tax Clearance Certificate;

xix. State Individual Consent to Disclosure of Tax Information;

xx. Federal Internal Revenue Service Tax Clearance Certificate;

xxi. Federal Individual Consent to Disclosure of Tax Information.

c. Level I, Parts A and B, Renewal Riverboat Gaming Application, DPSSP 6618 and 6619, including, but not limited to:

i. Part A-Instructions;

ii. Additional Application Information Required;

iii. Part B-Instructions;

iv. Definitions.

d. Level I, Renewal Suitability Gaming Application, Part A, DPSSP 6618, including, but not limited to:

i. Applicant Information;

ii. General Information;

iii. Records/Books Information;

iv. Professional Services Information;

v. Gaming Interest Information;

vi. General Information;

vii. Financial Disclosure Information;

viii. Affidavit of Full Disclosure;

ix. Applicant's Request to Release Information;

x. Verification;

xi. Release of All Claims;

xii. Business Tax Information Authorization Request;

xiii. Federal Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

xiv. Federal Internal Revenue Service Tax Clearance Certificate;

xv. State Department of Revenue And Taxation Consent to Disclosure of Tax Information;

xvi. Louisiana Department of Revenue and Taxation Tax Clearance Certificate.

e. Level I, Renewal Suitability Gaming Application, Part B, Personal History and Financial Record, DPSSP 6619, including, but not limited to:

i. Personal Information;

ii. Criminal History Information;

iii. Civil Litigation Information;

iv. Employment History;

v. Professional Licenses, etc., Information;

vi. Business Associations Information;

vii. Financial Information;

viii. General Information;

ix. Supplemental Page Information;

x. Verification;

xi. Affidavit of Full Disclosure;

xii. Individual's Request to Release Information;

xiii. Release of All Claims;

xiv. Individual Tax Information Authorization Request;

xv. Louisiana Department of Revenue and Taxation Tax Clearance Certificate;

xvi. State Individual Consent to Disclosure of Tax Information;

xvii. Federal Internal Revenue Service Tax Clearance Certificate;

xviii. Federal Individual Consent to Disclosure of Tax Information.

f. Casino Gaming Key Employee Permit Application, Instructions and Application, DPSSP 0074, including, but not limited to:

i. Application for Permit;

ii. Personal History and Financial Record;

iii. Personal Financial Questionnaire;

iv. Verification;

v. Affidavit of Full Disclosure;

vi. Release of All Claims;

vii. Individual Tax Information Authorization Request;

viii. Louisiana Department of Revenue and Taxation Tax Clearance Certificate;

ix. State Individual Consent to Disclosure of Tax Information;

x. Federal Internal Revenue Service Tax Clearance Certificate;

xi. Federal Individual Consent to Disclosure of Tax Information.

g. Key Riverboat Gaming Employee Renewal Application, DPSSP 0084, including, but not limited to:

i. Instruction Sheet;

ii. Application for Permit;

iii. Affidavit of Full Disclosure;

iv. Release of All Claims.

h. Riverboat and Landbased Casino Non-Key Gaming Employee Permit Application, DPSSP 0075, including but not limited to:

i. Permit Application;

ii. Gaming Employee Applicant Conditional Approval Agreement (Non-Key Gaming);

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual.

i. Non-Key Riverboat Gaming Employee Renewal Application, DPSSP 0065, including, but not limited to:

i. Instruction Sheet;

ii. Application for Permit;

iii. Employee Gaming Permit Renewal Affidavit;

iv. Release of All Claims.

j. Supplier of Significant Services (Marine Operations) Permit Application Individual Form Instructions and Application, DPSSP 0089:

i. Instructions;

ii. Personal Information;

iii. Criminal History Information;

iv. Military Service Data Information;

v. Civil Litigation Information;

vi. Employment History Information;

vii. Professional Licenses, etc., Information;

viii. Business Associations Information;

ix. Personal Financial Questionnaire;

x. Supplemental Page Information;

xi. Verification;

xii. Affidavit of Full Disclosure;

xiii. Individual's Request to Release Information;

xiv. Release of All Claims;

xv. Individual Tax Information Authorization Request;

xvi. Louisiana Department of Revenue and Taxation Tax Clearance Certificate;

xvii. State Individual Consent to Disclosure of Tax Information;

xviii. Federal Internal Revenue Service Tax Clearance Certificate;

xix. Federal Individual Consent to Disclosure of Tax Information.

k. Individual Marine Operation Permit Renewal Application, DSSP 0091, including, but not limited to:

i. Instruction Sheet;

ii. Application for Permit;

iii. Affidavit of Full Disclosure;

iv. Release of All Claims.

l. Casino Gaming Non-Gaming Supplier Permit Application, DPSSP 0076, including, but not limited to:

i. Application for Permit;

ii. Verification;

iii. Non-Gaming Application Request to Release Information and Release of Claims Company/Corporation/ Individual;

iv. Business Tax Information Authorization Request;

v. Tax Clearance Request.

m. Level II, Casino Gaming Permit Application Manufacturers and Suppliers, Part A, DPSSP 0073, including, but not limited to:

i. Instruction Page;

ii. Schedule of Fees;

iii. Application for Permit;

iv. Statement of Assets;

v. Statement of Liabilities;

vi. Verification;

vii. Affidavit of Full Disclosure;

viii. Release of All Claims;

ix. Individual Tax Information Authorization Request;

x. Applicant's Request to Release Information.

n. Level II, Casino Gaming Permit Application, Personal History and Financial Record, Part B, DPSSP 0077, including, but not limited to:

i. Personal Information;

ii. Personal Financial Questionnaire;

iii. Statement of Assets;

iv. Statement of Liabilities;

v. Verification;

vi. Affidavit of Full Disclosure;

vii. Individuals Request to Release Information;

viii. Release of All Claims;

ix. Individual Tax Information Authorization Request.

o. Gaming Permit/License Application for Manufacturers, Suppliers/Distributors and Service Entities, DPSSP 6613, including, but not limited to:

i. Instructions;

ii. Schedule of Fees;

iii. Application for Permit;

iv. Vendor Reciprocity Affidavit.

p. Non-Gaming Supplier Permit Application for Suppliers of Non-Gaming Goods/Services, DPSSP 6614, (In Accordance with Reciprocity Provisions of R.S. 27.91.E), including, but not limited to:

i. Instructions;

ii. Application for Permit;

iii. Vendor Reciprocity Affidavit;

iv. Request to Release Information and Release of Claims by Company/Corporation/Individual;

v. Tax Clearance Request;

vi. Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

vii. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (State);

viii. Internal Revenue Service Land Based Casino and Riverboat Gaming Tax Clearance Certificate (Federal).

q. Supplier of Significant Services (Marine Operations) Permit Application, DPSSP 0088, including, but not limited to:

i. Application for Permit;

ii. Business Financial Questionnaire;

iii. Statement of Assets;

iv. Statement of Liabilities;

v. Verification;

vi. Affidavit of Full Disclosure;

vii. Applicants Request to Release Information;

viii. Release of All Claims;

ix. Applicants Tax Information Authorization Request.

r. Non-Gaming Supplier Renewal Application, DPSSP 0090, including, but not limited to:

i. Application for Permit;

ii. Affidavit Form;

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual;

iv. Business Tax Information Authorization Request;

v. Tax Clearance Request.

s. Manufacturer/Supplier Renewal Application, DPSSP 0064, including, but not limited to:

i. Application for Permit;

ii. Affidavit Form;

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual;

iv. Business Tax Information Authorization Request;

v. Tax Clearance Request.

t. Fingerprint Cards

2. Land Based Casino

a. Casino Gaming Key Employee Permit Application Instructions and Application, DPSSP 0074, including, but not limited to:

i. Personal History and Financial Record;

ii. Personal Financial Questionnaire;

iii. Statement of Assets;

iv. Statement of Liabilities;

v. Verification;

vi. Affidavit of Full Disclosure;

vii. Individual's Request to Release Information;

viii. Release of All Claims;

ix. Individual Tax Information Authorization Request;

x. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (State);

xi. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (Federal);

xii. Businesses, Trusts, Estates, etc., Consent to Disclosure of Tax Information.

b. Gaming Key Employee Permit Renewal Application Packet, including, but not limited to:

i. Instructions;

ii. Gaming Key Employee Permit Renewal Application;

iii. Gaming Permit Affidavit;

iv. Request to Release Information and Release of Claims by Company/Corporation/Individual.

c. Riverboat and Landbased Casino Non-Key Gaming Employee Permit Application, DPSSP 0075, including, but not limited to:

i. Permit Application;

ii. Gaming Employee Applicant Conditional Approval Agreement (Non-Key Gaming);

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual.

d. Gaming Non-Key Employee Permit Renewal Application, including, but not limited to:

i. Instructions;

ii. Gaming Non-Key Employee Permit Renewal Application;

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual.

e. Gaming Permit/License Application for Manufacturers, Suppliers/Distributors and Service Entities (in Accordance with Reciprocity Provisions), DPSSP 6613, including, but not limited to:

i. Application for Permit;

ii. Vendor Reciprocity Affidavit.

f. Level II, Casino Gaming Permit Application Manufacturers and Suppliers, Part A, DPSSP 0073, including, but not limited to:

i. Schedule of Fees;

ii. Application for Permit;

iii. Statement of Assets;

iv. Statement of Liabilities;

v. Verification;

vi. Affidavit of Full Disclosure;

vii. Release of All Claims;

viii. Individual Tax Information Authorization Request;

ix. Applicant's Request to Release Information;

x. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (State);

xi. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (Federal);

xii. Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information.

g. Manufacturers and Suppliers Gaming Permit Renewal Application, including, but not limited to:

i. Instructions;

ii. Renewal Application;

iii. Gaming Permit Affidavit;

iv. Request to Release Information and Release of Claims by Company/Corporation/Individual;

v. Individual Tax Information Authorization Request;

vi. Business Tax Information Authorization Request;

vii. Tax Clearance Request.

h. Non-Gaming Supplier Permit Application for Suppliers of Non-Gaming Goods/Services (in Accordance with Reciprocity Provisions), DPSSP 6614, including, but not limited to:

i. Application for Permit;

ii. Vendor Reciprocity Affidavit;

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual;

iv. Tax Clearance Request;

v. Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

vi. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance (State);

vii. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance (Federal).

i. Casino Gaming Non-Gaming Supplier Permit Application, DPSSP 0076, including, but not limited to:

i. Application for Permit;

ii. Verification;

iii. Non-Gaming Application Request to Release Information and Release of Claims Company/ Corporation/Individual;

iv. Business Tax Information Authorization Request;

v. Tax Clearance Request;

vi. Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

vii. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (State);

viii. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (Federal).

j. Non-Gaming Suppliers Permit Renewal Application, including, but not limited to:

i. Instructions;

ii. Renewal Application;

iii. Affidavit;

iv. Non-Gaming Request to Release Information and Release of Claims by Company/Corporation/Individual;

v. Business Tax Information Authorization Request;

vi. Tax Clearance Request.

k. Level I, Suitability Gaming Application, Part A, including, but not limited to:

i. Application for License;

ii. Statement of Assets;

iii. Statement of Liabilities;

iv. Affidavit of Full Disclosure;

v. Applicant's Request to Release Information;

vi. Individual Tax Information Authorization Request;

vii. Verification.

l. Level II, Casino Gaming Permit Application Personal History and Financial Record Part B, DPSSP 0077, including, but not limited to:

i. Personal Information;

ii. Personal Financial Questionnaire;

iii. Statement of Assets;

iv. Statement of Liabilities;

v. Verification;

vi. Affidavit of Full Disclosure;

vii. Individual's Request to Release Information;

viii. Release of All Claims;

ix. Individual Tax Information Authorization Request;

x. Business, Trusts, Estates, etc., Consent to Disclose Tax Information;

xi. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (State);

xii. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (Federal).

m. Land Based Casino Gaming Division, Junket or Limousine Service Casino Gaming Permit Application, DPSSP 6611, including, but not limited to:

i. Schedule of Fees;

ii. Application for Permit;

iii. Statement of Assets;

iv. Statement of Liabilities;

v. Verification;

vi. Affidavit of Full Disclosure;

vii. Release of All Claims;

viii. Individual Tax Information Authorization Request;

ix. Applicant's Request to Release Information;

x. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (State);

xi. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (Federal);

xii. Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information.

n. Gaming Device Shipment Notification, including, but not limited to:

i. Gaming Device Shipment Notification, DPSSP 6501;

ii. Gaming Device Shipment Notification (Supplemental), DPSSP 6502;

o. Finger Print Cards.

3. Video Poker

a. Video Gaming Application, DPSSP 0031;

b. Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

c. Affidavit of Full Disclosure, DPSSP 0036;

d. Request to Release Information, DPSSP 0037;

e. Release of All Claims, DPSSP 0035;

f. Individual Consent to Disclosure of Tax Information;

g. Personal History Questionnaire, DPSSP 0032;

h. Personal Financial Questionnaire, DPSSP 0033;

i. Designated Representative/Manager Application Form, DPSSP 5403;

j. multiple use reporting form, DPSSP 6600;

k. Application for Video Poker Device Permit, DPSSP 0059;

l. Gaming Device Ownership Transfer Notification, DPSSP 0052;

m. Video Gaming Devise Service/Repair Form, DPSSP 0040;

n. Pari-Mutuel Wagering Facility Monthly Report, DPSSP 0046;

o. Authorization Agreement for Pre-Authorized Payments, DPSSP 0038;

p. Video Gaming Device Shipment Notification, DPSSP 0043;

q. Minimum Monthly Fuel Sales Report, DPSVGD 1011;

r. Monthly Fuel Sales Meter Reading Report, DPSVGD 1012;

s. Renewal Application, DPSSP 0049;

t. Renewal Affidavit/Certification, DPSSP 0051;

u. Finger Print Cards;

v. Video Draw Poker Associated Business Entity Form, DPSSP 6504;

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v. video draw poker associated business entity form, DPSSP 6504;

w. application withdrawal/license surrender form, LGCBVP 0100;

x. surrender waiver request form, LGCBVP 0101.

4. Live Racing Facility Slot Machine Gaming

a. Level I, Part A, Suitability Gaming Application, DPSSP 6616, including, but not limited to:

i. Instructions;

ii. Application or Gaming License or Suitability Approval Application, Business Entity Form;

iii. Applicant Information;

iv. Ownership Interest;

v. General Information;

vi. Records/Books Information;

vii. Professional Services Information;

viii. Gaming Information (Miscellaneous);

ix. General Applicant Information;

x. Financial Disclosure Information;

xi. Affidavit of Full Disclosure;

xii. Applicant's Request to Release Information;

xiii. Verification;

xiv. Release of All Claims;

xv. Business Tax Information Authorization Request;

xvi. Federal Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

xvii. Federal Internal Revenue Service Gaming Tax Clearance Certificate;

xviii. State Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

xix. Louisiana Department of Revenue and Taxation Tax Clearance Certificate.

b. Level I, Part B, Personal History and Financial Record Suitability Gaming Application, DPSSP 6617, including, but not limited to:

i. Instructions;

ii. Personal History and Financial Record Suitability Gaming Application;

iii. Personal Information;

iv. Criminal History Information;

v. Civil Litigation Information;

vi. Military Service Data Information;

vii. Employment History Information;

viii. Professional Licenses, etc., Information;

ix. Business Associations Information;

x. Financial Information;

xi. General Information;

xii. Supplemental Page Information;

xiii. Verification;

xiv. Affidavit of Full Disclosure;

xv. Individual's Request to Release Information;

xvi. Release of All Claims;

xvii. Individual Tax Information Authorization Request;

xviii. Louisiana Department of Revenue and Taxation Tax Clearance Certificate;

xix. State Individual Consent to Disclosure of Tax Information;

xx. Federal Internal Revenue Service Tax Clearance Certificate;

xxi. Federal Individual Consent to Disclosure of Tax Information.

c. Level I, Parts A and B Renewal Riverboat Gaming Application, DPSSP 6618 and 6619, including, but not limited to:

i. Part A-Instructions;

ii. Additional Application Information Required;

iii. Part B-Instructions;

iv. Definitions.

d. Level I, Renewal Suitability Gaming Application, Part A, DPSSP 6618, including, but not limited to:

i. Applicant Information;

ii. General Information;

iii. Records/Books Information;

iv. Professional Services Information;

v. Gaming Interest Information;

vi. General Information;

vii. Financial Disclosure Information;

viii. Affidavit of Full Disclosure;

ix. Applicant's Request to Release Information;

x. Verification;

xi. Release of All Claims;

xii. Business Tax Information Authorization Request;

xiii. Federal Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

xiv. Federal Internal Revenue Service Tax Clearance Certificate;

xv. State Department of Revenue and Taxation Consent to Disclosure of Tax Information;

xvi. Louisiana Department of Revenue and Taxation Tax Clearance Certificate.

e. Level I, Renewal Suitability Gaming Application, Part B, Personal History and Financial Record, DPSSP 6619, including, but not limited to:

i. Personal Information;

ii. Criminal History Information;

iii. Civil Litigation Information;

iv. Employment History;

v. Professional Licenses, etc., Information;

vi. Business Associations Information;

vii. Financial Information;

viii. General Information;

ix. Supplemental Page Information;

x. Verification;

xi. Affidavit of Full Disclosure;

xii. Individual's Request to Release Information;

xiii. Release of All Claims;

xiv. Individual Tax Information Authorization Request;

xv. Louisiana Department of Revenue and Taxation Tax Clearance Certificate;

xvi. State Individual Consent to Disclosure of Tax Information;

xvii. Federal Internal Revenue Service Tax Clearance Certificate;

xviii. Federal Individual Consent to Disclosure of Tax Information.

f. Key Riverboat Gaming Employee Permit Application, DPSSP 0074, including, but not limited to:

i. Application for Permit;

ii. Personal History and Financial Record;

iii. Personal Financial Questionnaire;

iv. Verification;

v. Affidavit of Full Disclosure;

vi. Release of All Claims;

vii. Individual Tax Information Authorization Request;

viii. Louisiana Department of Revenue and Taxation Tax Clearance Certificate;

ix. State Individual Consent to Disclosure of Tax Information;

x. Federal Internal Revenue Service Tax Clearance Certificate;

xi. Federal Individual Consent to Disclosure of Tax Information.

g. Key Riverboat Gaming Employee Renewal Application, DPSSP 0084, including but not limited to:

i. Instruction Sheet;

ii. Application for Permit;

iii. Affidavit of Full Disclosure;

iv. Release of All Claims.

h. Riverboat and Landbased Casino Non-Key Gaming Employee Permit Application, DPSSP 0075, including but not limited to:

i. Permit Application;

ii. Gaming Employee Applicant Conditional Approval Agreement (Non-Key Gaming);

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual.

i. Non-Key Riverboat Gaming Employee Renewal Application, DPSSP 0065, including, but not limited to:

i. Instruction Sheet;

ii. Application for Permit;

iii. Employee Gaming Permit Renewal Affidavit;

iv. Release of All Claims.

j. Casino Gaming Non-Gaming Supplier Permit Application, DPSSP 0076, including, but not limited to:

i. Application for Permit;

ii. Verification;

iii. Non-Gaming Application Request to Release Information and Release of Claims Company/Corporation/ Individual;

iv. Business Tax Information Authorization Request;

v. Tax Clearance Request.

k. Casino Gaming Permit Application, Manufacturer and Suppliers, Part A, DPSSP 0073, including, but not limited to:

i. Instruction Page;

ii. Schedule of Fees;

iii. Application for Permit;

iv. Statement of Assets;

v. Statement of Liabilities;

vi. Verification;

vii. Affidavit of Full Disclosure;

viii. Release of All Claims;

ix. Individual Tax Information Authorization Request;

x. Applicants Request to Release Information.

l. Level II Casino Gaming Permit Application, Personal History and Financial Record, Part B, DPSSP 0077, including, but not limited to:

i. Personal Information;

ii. Personal Financial Questionnaire;

iii. Statement of Assets;

iv. Statement of Liabilities;

v. Verification;

vi. Affidavit of Full Disclosure;

vii. Individual's Request to Release Information;

viii. Release of All Claims;

ix. Individual Tax Information Authorization Request.

m. Gaming Permit/License Application for Manufacturers, Suppliers/Distributors and Service Entities, DPSSP 6613, including, but not limited to:

i. Instructions;

ii. Schedule of Fees;

iii. Application for Permit;

iv. Vendor Reciprocity Affidavit.

n. Non-Gaming Supplier Permit Application for Suppliers of Non-Gaming Goods/Services, DPSSP 6614, including, but not limited to:

i. Instructions;

ii. Application for Permit;

iii. Vendor Reciprocity Affidavit;

iv. Request to Release Information and Release of Claims by Company/Corporation/Individual;

v. Tax Clearance Request;

vi. Business, Trusts, Estates, etc., Consent to Disclosure of Tax Information;

vii. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (State);

viii. Internal Revenue Service Land Based Casino and Riverboat Gaming Tax Clearance Certificate (Federal).

o. Non-Gaming Supplier Renewal Application, DPSSP 0090, including, but not limited to:

i. Application for Permit;

ii. Affidavit Form;

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual;

iv. Business Tax Information Authorization Request;

v. Tax Clearance Request.

p. Manufacturer/Supplier Renewal Application, DPSSP 0064, including, but not limited to:

i. Application for Permit;

ii. Affidavit Form;

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual;

iv. Business Tax Information Authorization Request;

v. Tax Clearance Request.

q. Finger Print Cards

5. Reciprocity

a. Gaming Permit License Application for Manufactures, Suppliers/Distributors and Service Entities, DPSSP 6613, including but not limited to:

i. Application for Permit;

ii. Vendor Reciprocity Affidavit.

b. Non-Gaming Supplier Permit Application for Suppliers of Non-Gaming Goods/Services, DPSSP 6614, including but not limited to:

i. Application for Permit;

ii. Vendor Reciprocity Affidavit;

iii. Request to Release Information and Release of Claims by Company/Corporation/Individual;

iv. Tax Clearance Request;

v. Business, Trusts, Estates, etc.;

vi. Consent to Disclosure of Tax Information;

vii. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (State);

viii. Louisiana Department of Revenue and Taxation Land Based Casino and Riverboat Gaming Tax Clearance Certificate (Federal).

6. General forms:

a. request for permission to reapply, DPSSP 0060.

b. labor organization registration statement, LGCBGEN 0100.

7. Fantasy Sports

a. Fantasy Sports Application, DPSSP 6729, including, but not limited to:

i. instructions;

ii. application for fantasy sports license;

iii. applicant information;

iv. ownership interests;

v. general information;

vi. records/books information;

vii. professional services information;

viii. gaming information (miscellaneous);

ix. general applicant information;

x. financial disclosure information;

xi. affidavit of full disclosure;

xii. applicant's request to release information;

xiii. verification;

xiv. release of all claims;

xv. business tax information authorization request;

xvi. federal business, trusts, estates, etc., consent to disclosure of tax information;

xvii. Federal Internal Revenue Service gaming tax clearance certificate;

xviii. state business, trusts, estates, etc., consent to disclosure of tax information;

xix. Louisiana Department of Revenue and Taxation tax clearance certificate.

b. application withdrawal license surrender form, LGCB6707-22.

8. Sports Wagering

a. Sports Wagering License Application, DPSSP 6760, including, but not limited to:

i. instructions;

ii. application for sports wagering license;

iii. applicant information;

iv. ownership interests and organizational information;

v. general information;

vi. records/books information;

vii. vendor information;

viii. gaming information (miscellaneous);

ix. general applicant information;

x. financial disclosure information;

xi. affidavit of full disclosure;

xii. applicant's request to release information;

xiii. verification;

xiv. release of all claims;

xv. business tax information authorization request;

xvi. federal business, trusts, estates, etc., consent to disclosure of tax information;

xvii. Federal Internal Revenue Service gaming tax clearance certificate;

xviii. state business, trusts, estates, etc., consent to disclosure of tax information;

xix. Louisiana Department of Revenue and Taxation tax clearance certificate;

xx. affidavit for temporary certificate of authority;

xxi. business affidavit;

xxii. individual affidavit.

b. Sports Wagering Platform Provider Permit Application, DPSSP 6761 including, but not limited to:

i. instructions;

ii. application for sports wagering platform provider permit;

iii. applicant information;

iv. ownership interests and organizational information;

v. general information;

vi. records/books information;

vii. vendor information;

viii. gaming information (miscellaneous);

ix. general applicant information;

x. financial disclosure information;

xi. affidavit of full disclosure;

xii. applicant's request to release information;

xiii. verification;

xiv. release of all claims;

xv. business tax information authorization request;

xvi. federal business, trusts, estates, etc., consent to disclosure of tax information;

xvii. Federal Internal Revenue Service gaming tax clearance certificate;

xviii. state business, trusts, estates, etc., consent to disclosure of tax information;

xix. Louisiana Department of Revenue and taxation tax clearance certificate;

xx. affidavit for temporary certificate of authority;

xxi. business affidavit;

xxii. Individual Affidavit.

c. application withdrawal license surrender form, LGCB6707-22.

B. All applicants, licensees, permittees and persons required to be found suitable shall fully comply with all instructions contained in the prescribed forms and shall provide all documentation and information requested therein.

C. Any revisions, additions, or other modifications to the prescribed forms shall be made upon recommendation of the respective division and approval of the board.

La. Admin. Code tit. 42, § III-120

Promulgated by the Department of Public Safety and Corrections, Gaming Control Board, LR. 26:340 (February 2000), amended LR 40:1379 (July 2014), Amended LR 412176 (10/1/2015), Amended LR 42575 (4/1/2016), Amended LR 47256 (2/1/2021), Amended LR 47, Amended LR 4846 (1/1/2022), Amended LR 50264 (2/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S. 27:15 and 24.