Vous êtes sur la page 1sur 6

Georgia Lottery Corporation

Verification of Lawful Presence Within the United States


O.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 in
O.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 or
representation 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 Applicant
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
______ DAY OF ____________, 20___

_________________________
NOTARY PUBLIC
My Commission Expires:
FUN TIME AMUSEMENT GROUP INC
000016033

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 COAM
License 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 Business
Information page and each owners specific Part 2 - Personal Information page of the
attached application and sign on the designated signature line. Each owners signed Part
2- Personal Information page must benotarized.

2. Affidavit: A signed and sworn (notarized) Verification of Lawful Presence Within the
United 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 and
Nationality 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 your
affidavit. Attached is a complete list of acceptable Secure and Verifiable Documents.

3. Secure and Verifiable Document: A legible front and back copy of each owners
applicable 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.


Page 2
Required License Application Documents



4. Photo Identification: Attach a copy of one of the following forms of photo identification to
the 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: Each applicant (primary top 10) that answered yes to any of the questions
listed 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 business
operating as a COAM manufacturer, distributor, location owner or location operator within
the 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





Acceptable Secure and Verifiable Documents
Under 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, 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. 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 United
States 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 Immigration
Services (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 agency
is required by federal law to accept a document or other form of identification for proof
of or documentation of identity, that document or other form of identification will be deemed a
secure and verifiable document solely for that particular program or administration of that particular
public benefit.

11. List each owner, shareholder, member and offcer 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 If Yes, 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 Identifer Number:
Coin Operated Amusement Machine Application
GEORGIA LOTTERY CORPORATION P.O. Box 56927 Atlanta, GA 30343
1-800-746-8546 - OPTION #4 - Retailer Contracts Administration
PART 1 - Business Information
Revised May 2014
CLASS B MASTER LICENSE ID#:
1. Corporate or legal name:
2. Type of Ownership: Sole Proprietor Partnership Corporation Non-Proft
LLC (Corporation) LLC (Partnership) Other(specify):
3. Store Name or DBA Name:
5. Mailing Address:
Address Line 1:
Address Line 2:
City: State: Zip Code:
9. Federal Employer Identifcation Number(EIN)/SS Number: 10. Withholding Tax Number:
15. Who maintains the business entity's fnancial and business records?
16. Where are these fnancial 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 flings?
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
FUN TIME AMUSEMENT GROUP INC

FUN TIME AMUSEMENT GROUP INC


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


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 offcer 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 fne 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 fled 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 (18 through 24) 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:
City: State: Zip Code:
Signature Print Name Date
Revised May 2014
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 Applicants
application to become a Bona Fide Coin Operated Amusement Machine (COAM) licensee is true and correct in every respect. Specifcally, I certify that I have
reviewed both the Applicants Business Information Page(s) as submitted, and my own Owner Information Pages for this application, and I certify that the information
contained 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 order
to satisfy the GLC requirements for qualifcation of the Applicant as a COAM Licensee, which investigations may include, without limitation, criminal history record
information, credit history records, tax records, public records and other offcial records, and the investigation generally of any other matter relating to both me and
the 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 required
to furnish certain information for use in determining my qualifcations. I hereby authorize GLC to request a credit report, conduct a criminal background investigation,
or conduct any other investigation as may be necessary to process my COAM Licensee Application. I authorize GLC to share any such information, privileged,
confdential 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 any
and all manners consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out of the relationship
between 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 of
my signature. This release will expire upon the fnal termination of the Applicants COAM License obligations to the GLC. I further understand and acknowledge that
providing 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 Administration
This 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 Identifcation (ID) is required to be presented to and verifed by Notary Public. Type of ID: ID Number:
12. List all other names you have used, including nicknames, surnames
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 kyilea@bob.cc (404)207-3966 416223366
123 elm st
Mobile AL 36693
Mobile
Al Mobile
6 180 black black

Kyi CEO
05/20/2014