Free 11-20.PDF - Indiana

RENEWAL OF RIVERBOAT OWNERS'S LICENSE APPLICATION FORM SCHEDULE OF EXHIBITS FOR CONDENTIAL INFORMATION This Schedule relates to the Application of:

Complete Name of Applicant to conduct a Riverboat Gambling Operation on the in the County of
If an Exhibit is not applicable, indicate " N.A.".

River/Lake with Docking Facilities at during calendar years 20__ to 20__.

Exhibit Number 16 17 18 19 20(a) 20(b) 21 22(a) 22(b) 23(a) 23(b) 23 (c)

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

Official Title

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On behalf of __________________________________________________________________, (Applicant's Name) I, ___________________________________________________________________________, (Affiant) hereby acknowledge that the Indiana Gaming Commission will require supplemental materials in order to carry out its statutory duties. ______________________________________________, (Applicant) hereby agrees to submit supplemental materials as requested by the commission.

__________________________________________ Signature By _______________________________________ Its _______________________________________ Date _____________________________________

AFFIRMATION I affirm, under the penalties of perjury, that the information set forth in this document is true and complete, to the best of my knowledge.

_________________________________________ Signature _________________________________________ Printed Name _________________________________________ Date

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APPLICANT'S REQUEST TO RELEASE INFORMATION

TO:_____________________________________________________________________________ FROM:__________________________________________________________________________ Applicant's Name 1. Applicant hereby authorizes and requests all persons or entities to whom this request is presented having information relating to or concerning Applicant to furnish such information to a duly appointed agent of the Indiana Gaming Commission, whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or other legal privilege. 2. Applicant hereby authorizes and requests all persons or entities to whom this request is presented having documents relating to or concerning Applicant to permit a duly appointed agent of the Indiana Gaming Commission to review and copy any such documents, whether or not such documents would otherwise be protected from disclosure by any constitutional, statutory or other legal privilege. 3. If the person or entity to whom this request is presented is a brokerage firm, bank, savings and loan, or other financial institution or an officer of same, Applicant hereby authorizes and requests that a duly appointed agent of the Indiana Gaming Commission be permitted to review and obtain copies of any and all documents, records or correspondence pertaining to Applicant, including but not limited to past loan information, notes cosigned by Applicant, checking account records, savings deposit records, safe deposit box records, passbook records, and general ledger folio sheets. 4. Applicant hereby makes, constitutes, and appoints any duly appointed agent of the Indiana Gaming Commission Applicant's true and lawful attorney in fact for Applicant in Applicant's name, place, stead, and on Applicant's behalf and for Applicant's use and benefit: (a) to request, review, copy, sign for, or otherwise act for investigative purposes with respect to documents and information in the possession of the person or entity to whom this request is presented as Applicant might; to name the person or entity to whom this request is presented and insert that person's or entity's name in the appropriate location on this request; to place the name of the Indiana Gaming Commission agent presenting this request in the appropriate location on this request.

(b)

(c)

5. Applicant grants to said attorney in fact full power and authority to do, take, and perform all and every act and thing whatsoever requisite, proper, or necessary to be done, in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as Applicant might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that said attorney in fact, or his substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted.

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6. This power of attorney ends eighteen (18) months from the date of execution or at the termination of all licenses issued to Applicant by the Indiana Gaming Commission, whichever occurs later. 7. Applicant has filed with the Indiana Gaming Commission an "Application". Applicant understands that Applicant is seeking the granting of a privilege and acknowledges that the burden of proving Applicant's qualifications for a favorable determination is at all times on Applicant. Applicant accepts any risk of adverse public notice, embarrassment, criticism, or other action of financial loss, which may result from action with respect to this Application. 8. Applicant does, for itself, its heirs, executors, administrators, successors and assigns, hereby release, remise, and forever discharge the person or entity to whom this request is presented, and his or its agents and employees from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which Applicant ever had, now has, may have, or claims to have against the person or entity to whom this request is presented or his or its agents or employees arising out of or by reason of complying with this request. 9. Applicant agrees to indemnify and hold harmless the person or entity to whom this request is presented and his or its agents and employees from and against all claims, damages, losses, and expenses, including reasonable attorneys' fees arising out of or by reason of complying with this request. 10. A reproduction of this request by photocopy shall be for all intents and purposes as valid as the original.

IN WITNESS WHEREOF, I have executed this request at ___________________________________, (City) ___________________________ on the ____________ day of ___________________, 20______. (State) ________________________________________ Applicant By: ____________________________________ Its: ____________________________________

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L STATE OF ________________________ SS:

COUNTY OF ______________________ Before me, the undersigned, a Notary Public in and for said County and State, personally appeared ____________________________________ and acknowledged the execution of the foregoing instrument as his/her voluntary act and deed.

WITNESS, my hand and Notarial Seal, this _________________ day of _______________, 20___.

__________________________________________ Notary Public, Written Signature

__________________________________________ Notary Public, Printed Signature

My commission expires: _______________________ County of Residence: _________________________

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The undersigned has filed with the Indiana Gaming Commission ("Commission") certain forms and documents in connection with a written request for licensing renewal by the Commission ("Application"). In consideration of the assurance by the Commission that no vote on said Application will be taken except after a deliberate, intensive and thorough investigation of the undersigned, including but not limited to background, associates, and finances, the undersigned does for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise, and forever discharge the State of Indiana, the Commission, its members, agents, and employees, from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which the undersigned ever had, now has, may have, or claim to have against any or all of said entities or individuals arising out of or by reason of the processing or investigation of or other action relating to the Renewal Application. I, the duly authorized _______________________ of the undersigned, have read this affidavit and understand its terms. On behalf of and in accordance with the instructions of the undersigned, I execute it with full knowledge that the undersigned will be bound hereby. IN WITNESS WHEREOF, I have executed this request at ____________________________________, _________________________ on the _______________________ day of _____________________, 20____.

__________________________________________ Applicant STATE OF _______________________ SS: COUNTY OF _____________________ By: ________________________________ Its: ________________________________

Before me, the undersigned, a Notary Public in and for said County and State, personally appeared __________________________________ and acknowledged the execution of the foregoing instrument as his/her voluntary act and deed. WITNESS, my hand and Notarial Seal, this ____________ day of __________________, 20____.

My commission expires ______________________

__________________________________________ Notary Public, Written Signature __________________________________________ Notary Public, Printed Signature

County of residence _________________________

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State of ______________________ SS: County of ____________________ I, _______________________________, being the duly authorized _____________________________ (Officer) (Office) of __________________________________, being first duly sworn upon oath or affirmation, depose and state: (Name of Applicant) that, except as reported in Applicant's Renewal Application ("Application"), Applicant has no agreements or understandings with any person or entity and no present intent to hold as agent, nominee or otherwise any interest in the Application; that, except as reported in the Application, Applicant has no agreements or understandings with any person or entity and no present intent to pay any sums of money or give anything of value as, including but without limitation, a finder's fee or commission to any person or entity related to the acquisition of any interest in the Application; that, except as reported in the Application, Applicant has no agreements or understandings and no present intent to pay any sums of money or give anything of value as, including, but without limitation, a finder's fee or commission to any person or entity related to the sale of any interest in the Application; that any funds used or to be used, and any liabilities incurred or to be incurred by Applicant in the acquisition of any interest in the Application were not provided to Applicant or made available to Applicant through the efforts of any person or entity not reported in the Application; that, except as reported in the Application, no person or entity has provided collateral for or guaranteed payment of any loans made to Applicant which relate to the Application.

I, the duly authorized ______________________ of the undersigned, have read this Affidavit of Full (Office) Disclosure and understand its terms. On behalf of and in accordance with the instructions of the undersigned, I execute it with full knowledge that the undersigned will be bound hereby.

__________________________________ Applicant By: ________________________________ Its: ________________________________ Address: ___________________________ ___________________________

STATE OF __________________________ SS:

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COUNTY OF ________________________ Before me, the undersigned, a Notary Public in and for said County and State, personally appeared _________________________________ and acknowledged the execution of the foregoing instrument as his/her voluntary act and deed. WITNESS, my hand and Notarial Seal, this ______________ day of ________________, 20____.

___________________________________ Notary Public, Written Signature

___________________________________ Notary Public, Printed Signature

My commission expires : ______________________ County of Residence: _________________________

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VERIFICATION

I, ___________________________________, being the duly authorized _________________________ (Officer) (Office) of _______________________________________, being first duly sworn upon oath or affirmation depose and (Name of Applicant) state: 1. 2. On behalf of Applicant I submit this Application. I swear (or affirm) and certify that the information contained in this application is true, complete and accurate to the best of my knowledge and belief.

______________________________ Applicant

STATE OF ________________________ SS: COUNTY OF ______________________

By: _______________________________ Its: _______________________________

Before me, the undersigned, a Notary Public in and for said County and State, personally appeared __________________________________ and acknowledged the execution of the foregoing instrument as his/her voluntary act and deed. WITNESS, my hand and Notarial Seal, this _____________ day of ___________________, 20____.

My commission expires ________________________

__________________________________________ Notary Public, Written Signature __________________________________________ Notary Public, Printed Signature

County of residence ___________________________

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DO NOT SUBMIT THIS FORM. THIS DRAFT AUTHORIZATION REQUEST HAS BEEN SUPPLIED TO YOU FOR INFORMATIONAL PURPOSES. YOU WILL BE REQUIRED TO EXECUTE THIS AUTHORIZATION OR A SIMILAR AUTHORIZATION IN THE PRESENCE OF A COMMISSION AGENT AS PART OF THE APPLICATION PROCESS.

INDIANA GAMING COMMISSION South Tower, Suite 950 115 W. Washington Indianapolis, Indiana 46204-3408 Telephone: (317) 233-0046 *** Corporate Tax Information Authorization Request *** I, _________________________________________, the duly authorized ______________________________(Corporate Office) of _______________________________________, Inc., a ___________________________ corporation (the Corporate Name) (State of Incorporation) ("Corporation"), Federal Identification Number: ________________________________, on behalf of the Corporation, do hereby authorize: John J. Thar, Esq. Executive Director Indiana Gaming Commission South Tower, Suite 950 115 W. Washington Indianapolis, Indiana 46204-3408 Telephone: (317) 233-0046 or any of the Commission's authorized agents to receive from or inspect confidential returns, or return information, i.e., all information in the possession of the Internal Revenue Service with respect to my tax liability for the years ____________ through __________ inclusive. _________________________, Inc. By:___________________________ Its:___________________________ DATED: ________________________, 20_______ WITNESSED: ______________________________ INDIANA GAMING COMMISSION

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