Request for Background Information

REQUEST FOR BACKGROUND INFORMATION

It is critical that the integrity and security of the Michigan Lottery be maintained. Therefore, every Bidder(s) and their owners and officers must be willing to disclose background information.

The Michigan Lottery reserves the right to require additional information from the Bidder(s) at anytime. BIDDER INFORMATION 1. Business Name:

2. Doing Business As (DBA):

3. Ownership Type: 4. Publicly Traded? YES NO

5. US Federal Employer Identification Number/Social Security Number (or non-U.S. equivalent):

6. Physical Business Address: County:

City: State/Province: Zip: Country:

7. Mailing Address: Same as Physical Business Address County:

City: State/Province: Zip: Country:

8.Telephone Number ( ) 9. Facsimile Number ( ) 10. Company Website Address: 11. Date business was established:

Criminal & Civil History 12. Has the Bidder been charged or convicted of a felony, misdemeanor or civil offense? No Yes If you answered Yes, complete the following: Disposition/J Date of Charge Final Disposition or Name of Court and Address Nature of Charge or Arrest or Suit udgment or Arrest or Suit Judgment Date

Tax Liability 13. Does the Bidder have any outstanding tax related issues with the Internal Revenue Service, any state or local municipality, including but not limited to delinquencies, judgments, payment plans, or liens? No Yes If checked yes, provide explanation. Taxing Authority Address (street, city, state, zip, country)

Authorized Contact 14. Authorized contact responsible for completing application Name (last, first, middle) Title Telephone Number ( ) Email Address: Fax Number: Preferred Communication ( ) Email Fax 15. List the three (3) largest subcontractors to the Bidder. N/A If checked N/A, provide explanation: Subcontractor Name Address (street, city, state, zip, country) Type of Subcontractor

Authority: Act 239, 1972 as amended. BSL-E-2244(1/13)

1 OWNERSHIP INFORMATION 16. In the table below, list individuals and/or businesses owning 5 % or greater of equity interest of the Bidder. OWNER INFORMATION [INDIVIDUALS] Resident Address D.L. % Name (last, first, mi) Birth Date SSN Drivers License # (street, city, state, zip, country) State

OWNER INFORMATION [BUSINESSES] Business Name Business Address (street, city, state, zip, country) Established FEIN % Date

Tax Liability 17. Do the owners have any outstanding tax related issues with the Internal Revenue Service, any state or local municipality, including but not limited to delinquencies, judgments, payment plans, or liens? No Yes If checked yes, provide explanation. Taxing Authority Address (street, city, state, zip, country)

Criminal & Civil History 18. Have any owners been charged or convicted of a felony, misdemeanor or civil offense? No Yes If you answered Yes, complete the following: Date of Disposition/ Final Disposition or Owner’s Name (last, first, middle) Charge or Nature of Charge or Arrest or Suit Judgment Name of Court and Address Judgment Arrest or Suit Date

OFFICERS 19. List all Principal executive, financial and operations individuals (i.e. “officers/directors/managers”) Resident Address Birth Date Drivers D.L Title Name (last, first, mi) SSN (street, city, state, zip, country) License # State

Tax Liability 20. Do any officers have any outstanding tax related issues with the Internal Revenue Service, any state or local municipality, including but not limited to delinquencies, judgments, payment plans, or liens? No Yes If checked yes, provide explanation. Taxing Authority Address (street, city, state, zip, country)

2 Criminal & Civil History 21. Have any officers been charged or convicted of a felony, misdemeanor or civil offense? No Yes If you answered Yes, complete the following: Date of Disposition/ Final Disposition or Officer’s Name (last, first, middle) Charge or Nature of Charge or Arrest or Suit Judgment Name of Court and Address Judgment Arrest or Suit Date

______

Name of Bidder : ___

I certify that the information I have given on this form is true and complete. I understand that any misrepresentation or falsification may result in rejection of the proposal or in termination of a contract with the Michigan Lottery.

Dated: ______

______SIGNATURE OF AUTHORIZED AGENT

______PRINT NAME & TITLE

Acknowledged before me in ______County, State of ______on this ______day of ______20____.

______

______, Notary Public

State of ______, County of ______

Acting in the County of ______

My commission expires: ______