Free 499851-10.PDF - Indiana

State Form 49985 (R/4-01) Form approved by State Board of Accounts, 2001

INDIANA APPLICATION FOR RENEWAL OF RIVERBOAT OWNER LICENSE

This application contains: Section A: Non Confidential Application Information and Section B: Confidential Application information

Disclosure of this information is REQUIRED. The Indiana Gaming Commission will require applicants to disclose additional information not covered by this application. Failure to provide information could result in revocation processing of this application.

Indiana Gaming Commission South Tower, Suite 950 115 W. Washington Indianapolis, IN 46204-3408 (317) 233-0046

INSTRUCTIONS FOR OWNER'S RENEWAL LICENSE APPLICATION FORM

APPLICANT FOR RENEWAL OF AN OWNER'S LICENSE IS SEEKING A PRIVILEGE. THE BURDEN OF PROVING ITS QUALIFICATIONS TO RECEIVE SUCH A RENEWAL IS AT ALL TIMES ON THE APPLICANT. APPLICANT MUST ACCEPT ANY RISK OF ADVERSE PUBLIC NOTICE, EMBARRASSMENT, CRITICISM, OR OTHER ACTION, OR FINANCIAL LOSS, WHICH MAY RESULT FROM ACTION WITH RESPECT TO THIS APPLICATION, AND EXPRESSLY WAIVES ANY CLAIM FOR DAMAGES AS A RESULT THEREOF. INFORMATION NOT CALLED FOR IN THIS APPLICATION OR IN ADDITION TO THAT PROVIDED IN RESPONSE TO THIS APPLICATION MAY BE REQUESTED. APPLICANT SHALL PROVIDE ALL INFORMATION, DOCUMENTS, MATERIALS AND CERTIFICATIONS AT APPLICANT'S SOLE EXPENSE AND COST. The total cost of the investigation conducted pursuant to this application shall be borne by applicant. In addition, applicant is responsible for the payment of all application and license fees required under the Act and the posting of the bond required under the Act. Applicant should respond to the questions contained in this application to the best of its knowledge. Any misrepresentation or omission is grounds for application denial or disciplinary action by the Indiana Gaming Commission. Applicant is under a continuing duty to disclose promptly any changes in the information provided in the application and requested materials submitted to the commission. The duty to make additional disclosures continues throughout any period of the licensure granted by the commission. Type or print the answers to questions in black ink. If the answer or material response to a question has been provided in response to another portion of the application, refer to the other portion. The male pronoun when used in this application includes the masculine and feminine and neuter and also the plural, as appropriate. A. FORMS AND DOCUMENTS Submit one (1) bound original, three (3) bound copies and two (2) unbound copies of the application, labeled with applicant's name, along with the following information: 1. 2. 3. 4. 5. 6. Owner's Renewal License application form. Exhibits and schedules. Applicant's consent to release information. Release of all claims. Affidavit of full disclosure. Verification. 2

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Local government consent documents: Applicant shall submit copies of any ordinance, proclamation, resolution or other document supporting riverboat gambling and authorizing or approving the docking of riverboats conducting a riverboat gambling operation by the governing body of the municipality or county in which a proposed docking site is located. Documents of support: Applicant shall submit copies of any resolutions, testimonials, or letters of support and reference regarding the reputation, character and experience of applicant. B. APPLICATION FEE The following fee must be submitted with this application by applicant:

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A cashier's check or certified check in the amount of $5,000 for the initial payment of the renewal application fee. Any form of payment must be made payable to the State of Indiana. Any additional cost of investigation will be charged as provided by statute, rules, or interim written guidelines of the commission.

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TRANSMITTAL LETTER EXECUTIVE DIRECTOR INDIANA GAMING COMMISSION South Tower, Suite 950 115 W. Washington Indianapolis, IN 46204-3408 Dear Sir: ______________________________________________ does herewith make application (Applicant's Name) for Renewal of Owner's License to conduct a riverboat gambling operation in _________________________________________. (City or County) In accordance with the Riverboat Gambling Act, the applicant submits with this application a cashier's check or certified check in the amount of $5,000 and a statement indicating intent to continue the riverboat gambling operation. The applicant agrees to disclose and to require all of the persons associated with the applicant to disclose all information, documents and other material which the Indiana Gaming Commission may request at any time. The applicant agrees to furnish any additional information, documents and other material requested by the Indiana Gaming Commission, and agrees that such additional material shall be made a part of this application. The applicant acknowledges that neither the acceptance of this application nor the issuance of a renewal license implies that the Indiana Gaming Commission admits the truth of the statements made in this application, or its approval of the statements. The acceptance or the issuance of a renewal license shall not constitute waiver or agreement by the Indiana Gaming Commission with respect to any material contained in the application or supplement to application. The applicant further acknowledges that any license or any interest in any license issued by the Indiana Gaming Commission is not transferable, and that subsequent legislation, rule, or action by the commission may diminish the value of any license issued by the Indiana Gaming Commission to any extent possible. Respectfully submitted,

Applicant's Name By: Print name and Title Date:

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RENEWAL OF RIVERBOAT OWNER'S LICENSE

Name of renewal applicant

Doing Business As

Business address (Do not enter a P.O. Box)

City code

State

County

Zip Code

Telephone w/area

Federal Identification Number

__ __ Indiana Taxpayer Identification Number

Mailing Address

City

State

County

Zip Code

Fax Number

Attorney representing the Licensee before the Commission

Name of Attorney

Firm Name

Business Address

City

State

Zip Code

Phone Number Contact Person (if different from above)

Fax Number

Name of Contact Person

Title

Business Address

City

State

Zip Code

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A. Non Confidential Information 1. State whether Licensee is required to file reports with the Securities and Exchange Commission: Answer:_____________ If the answer is "yes", submit as Exhibit 1 a schedule identifying all documents filed with the Securities and Exchange Commission during the 5 years of licensure. 2. Submit as Exhibit 2 a current organizational chart of Licensee including names and titles. 3. Submit as Exhibit 3 a current corporate structure organizational chart showing all companies above and below the licensee. State if there have been any changes to the key persons, as defined in 68 IAC 1-157, with the Licensee: Answer: If the answer is "yes", submit as Exhibit 4, a list of all key person changes, the reason for separation from the Licensee, if the key person currently holds a gaming license in any other jurisdiction, their relationship to Licensee, and if the key person holds any ownership interest in Licensee. 5. Submit as Exhibit 5 any new business activities of any kind outside of Indiana. If none, initial here______ 6. Submit as Exhibit 6 any new gaming-related licenses obtained or being issued by any jurisdiction during the period of licensure. If none, initial here______ Submit as Exhibit 7 any stock or equity interest in a business entity that has been acquired by or on behalf of Licensee for any purpose other than investment. If none, initial here______ 8. Submit as Exhibit 8 Licensee's registered agent(s), legal service representatives, accounting service representatives, banking and financial service representatives. Submit as Exhibit 9(a) through (c), if in any other jurisdiction the Licensee or an affiliate has: (a) Voluntarily withdrawn a gaming license application? (b) Been refused a gaming license or been cited for lack of suitability? (c) Been a participant in any group, which has been denied a gaming license? If none, initial here_____

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Submit as Exhibit 10 if Licensee has experienced difficulties with or been cited by a regulatory or enforcement agency for infractions related to: (a) (b) (c) (d) Patron safety on board the riverboat, to include fires and water safety. Medical facilities available to patrons Sale of alcohol to patrons Patrons access to Licensee's docking site. If none, initial here_____

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Submit as Exhibit 11 describe any public reprimands, disciplinary actions, other citations, or agreements in lieu of disciplinary actions from any other jurisdiction to the Licensee or any affiliate. If none, initial here_____ Submit as Exhibit 12 if a licensing authority granting other than gaming-related licenses ever denied an application from Licensee, refused to renew a license or certificate for Licensee or subjected Licensee to disciplinary action. If none, initial here_____ Submit as Exhibit 13, a list of all legal actions, including pending or threatened litigation or administrative action not elsewhere disclosed in the application that the Licensee has been a named party during the current period of licensure. If none, initial here_____ Submit as Exhibit 14 any public official, officers or employees of any unit of government, or relatives of said public officials, officers, or employees, whom: (a) Directly or indirectly own any financial interest in Licensee or have options to obtain the same. (b) Have any beneficial interest in Licensee (c) Are the creditors of or hold any debt instrument issued by Licensee (d) Hold or have any interest in any contractual employment or service relationship with Licensee. If none, initial here_____

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Provide, as Exhibit 15, any amendment and/or addendum to the Development Agreement since the issuance of the Licensee's Certificate of Suitability. What future plans do you have for any discretionary giving? If none, initial here_____

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RENEWAL OF RIVERBOAT OWNERS'S LICENSE APPLICATION FORM SCHEDULE OF EXHIBITS FOR NON-CONFIDENTIAL INFORMATION This Schedule relates to the Application of: ________________________________________________________________ Complete Name of Applicant to conduct a Riverboat Gambling Operation on the Facilities at in the County of to 20__.
If an Exhibit is not applicable, indicate " N.A.".

River/Lake with Docking during calendar years 20__

Exhibit Number 1 2 3 4 5 6 7 8 9(a) 9(b) 9(c) 10 11 12 13 14 15

Person who made or directed preparation of Exhibit (state which)

Official Title

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B. Confidential Information 16. Submit as Exhibit 16 copies of Licensee's most recently filed State of Indiana and Federal income tax returns and copies of any amendments to the State of Indiana and Federal income tax returns filed during the current period of licensure. Submit as Exhibit 17 if Licensee has been delinquent in the payment of, or in dispute over the filings of, any tax required under federal, state or municipal law. This information is to include but not limited to: late filings of RG-1 through RG-9 for the past 5 years indicating the date and reason for the late filing and any action to seek a tax refund, credit, etc. Submit as Exhibit 18 if any federal, state or municipal tax penalties or interest assessed against Licensee as the result of an audit. This information is to include but not limited to: Title 31 compliance reviews conducted by the Internal Revenue Service. Submit as Exhibit 19 if Licensee, key person, or occupational license level 1 holder has been involved in an investigation by any federal, state or municipal agency. Submit as Exhibit 20(a) and (b), as applicable, copies of the following documents which apply to Licensee: (a) an annual balance sheet for each of the five (5) years the licensee has been in operation. (b) the amount and nature of any anticipated future investments in the Indiana Riverboat Project. 21. Submit as Exhibit 21 what your company has done over the past five (5) years, programmatically and financially, to address problem gambling in your community. Additionally, what does your company plan to do over the next three (3) years, programmatically and financially, to address problem gambling in your community. In the area of workforce development, submit as Exhibit 22(a) and (b): (a) What has your company done over the past five (5) years to develop and retain your present workforce? i.e. fringe benefits, insurance & employee incentives. (b) What has your company done over the past five (5) years to develop a future workforce? 23. Submit as Exhibit 23(a) through (c) the following information which will be utilized for a financial analysis: (a) For the Parent/Public Company, the last three (3) years of the following information: 1. Annual Reports 2. 10K's and 10Q's 3. Most recent prospectus for debt offering/refinancing (b) For the Indiana property (past three (3) years). 1. Budget 2. Balance Sheet 3. Cash flow statement 4. Income statement (profit/loss) 5. Owners equity statement (c) For the Indiana property (next three (3) years). 9

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Budget Balance sheet Cash flow statement Pro forma income statements

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