County/City Lottery (Keno) Forms

Printing Instructions

Most of these forms are available in a "Fill-able" format, meaning you can view, complete, and print the form on your computer. These forms use the features provided with Adobe Acrobat. Currently, there is no validation or verification of the information you enter, and you are responsible for entering and checking all required information. Instructions may require some information to be handwritten on the form (signatures, for example).

Note: The Acrobat Reader does not allow you to save your completed forms. You should print two copies --  one to mail, and one to keep for your records.

Applications

Form Title Form # Document
Licensing Checklist  

Licensing Checklist if applying for a keno license
Nebraska Application for County/City Lottery 50G

Application used by a county city or village to apply for a keno license
Schedule I, County/City Lottery Operator Application 50G, Sch. I

Application to apply to be a lottery operator for keno
Schedule II, County/City Lottery Sales Outlet Location Application 50G, Sch. II

Application to apply to be a sales outlet for keno
Schedule III, County/City Lottery Worker Application 50G, Sch. III

Application to apply for a lottery worker license for keno
Nebraska Application for Manufacturers, Distributors, and Manufacturer-Distributors 50A

Application to apply for a Manufacturer/Distributor license
Instructions for Completing Fingerprint Application  

Fingerprint Instructions
Background Check Waiver  

Background Check Waiver

Reporting

Form Title Form # Document
Nebraska County/City Lottery Tax Return 51C

Keno Tax Return used by counties cities and villages
Schedule I, County/City Lottery Activity ReportForm 51C

Schedule attached to keno tax return for reporting income, expenses, and disbursements
Nebraska County/City Lottery Annual Report - View and Print Only 35K

Keno Annual Report filed by counties cities and villages

Miscellaneous

Form Title Form # Document
Request for Abatement of Penalty 21

Abatement of Penalty Request Form
Power of Attorney 33

Power of Attorney Application
Temporary Agency Agreement (TAA) for County/City Lottery Licenses TAA-50G

Form used by a keno applicant authorizing a temporary license pending approval of a permanent license
Personal History Record and Background Disclosure Form for Charitable Gaming Licensees and Nebraska (State) Lottery Vendors  

Personal History and Background Disclosure Form
A Summary of Your Rights Under the Fair Credit Reporting Act  

A Summary of Your Rights Under the Fair Credit Reporting Act
Affidavit by Spouse for Waiver of Fingerprinting and/or Personal History Record and Background Disclosure Form for Charitable Gaming Licensees  

Spousal Waiver of Fingerprinting
Nebraska Licensed Manufacturer-Distributors of Lottery Supplies and Equipment  

List of Licensed ManufacturerDistributors