Instructions For 2014 Alaska Amended Multiple-Beneficiary Permit Application
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1Instructions for 2014 Alaska Amended Multiple-
Beneficiary Permit Application
the delete box and complete all information boxes requested
Use the amended application to correct errors or make
under Change of Vendor Information. Use additional sheets as
changes to information submitted on your original 2014
necessary.
MBP’s application. Please allow three to four weeks for
your amended application to be processed.
MANAGER OF GAMES
Check the add box and enter all information requested on the form
This guide is to help you successfully complete the amended permit
for the new manager. Attach the new manager’s contract. Check
application and speed up its processing time. Use the amended
the delete box to remove a manager and enter all information
permit application to make changes to your original application.
requested on the form for the former manager. Attach additional
sheets as necessary.
MBP INFORMATION
Enter your organization’s federal employer identification number
MANDATORY ATTACHMENTS
(EIN) and the Multiple-Beneficiary Permittee’s (MBP) name. Only
Any attachment required with the original application must be
enter the mailing address if it has changed.
submitted with the Amended Application if there is a change.
Examples: a change in locations requires submittal of a new
MEMBER IN CHARGE OF GAMES
lease; appointment of a new manager requires submittal of a new
Enter the legal name, address, phone number, and social security
manager contract.
number for the primary and alternate members in charge, if they
have changed.
Please allow 3 to 4 weeks for your application to be processed.
CHANGE IN MBP MEMBER APPLICATION
Mail form 859A to:
If the membership of the MBP changes, check the add or delete
TAX DIVISION - GAMING GROUP
box and enter the permit number and name of organization being
ALASKA DEPARTMENT OF REVENUE
added or deleted. A change in membership requires a change in
PO BOX 110420
the MBP joint venture agreement. Attach a copy of the amended
JUNEAU, AK 99811-0420
agreement to the amended MBP application.
Use additional
sheets as necessary.
LEGAL QUESTIONS
If you answer “yes” to either question, you must submit the
person’s name, date of birth, social security number, and position
of responsibility.
SIGNATURE
The primary member in charge, alternate member in charge, and
the manager of games must each sign and date the application
under penalty of unsworn falsification.
CHANGE OF SUPERVISORY EMPLOYEES
Check the add or delete box to report changes of supervisory
employees. Enter the first name, middle initial, last name, social
security number, and the effective date of the change for each
supervisory employee that is added or deleted.
ACTIVITIES CONDUCTED BY MBP
Check the add box to request an additional permit. If the requested
activity is bingo or pull-tabs you must provide the physical address
for each bingo and /or pull-tab activity and a copy of the lease
agreement for each activities’ location. If the MBP is applying for
a special draw raffle permit, a detailed description of the special
draw must be attached to the application. If the MBP is applying
for a Calcutta permit, a statement providing the name of the event,
the date, and the physical address of the Calcutta auction. The
physical location of the Calcutta event must be attached to the
application.
CHANGE OF VENDOR INFORMATION
Check the add box to request a Vendor Pull-Tab permit and enter
the name of the bar or liquor store, its physical address, city and
zip code. You must complete and attach a Vendor Registration
Form for each new vendor added. To delete a vendor(s) check
0405-859Ai Rev 08/30/13
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