Department of Public Safety s1

STATE OF IOWA DEPARTMENT OF PUBLIC SAFETY DIVISION OF CRIMINAL INVESTIGATION

CLASS C BACKGROUND

NAME: First Middle Maiden Last Date of Birth

Social Security Number: Have you ever been licensed for Iowa Gaming?

Casino or Boat Name: Position Applied For:

Do you have a Driver’s License? State: Number:

DCI Case # Upgrade? Yes No FOR Date Reviewed: Previous DCI Case # OFFICIAL Initials ______I-______USE ONLY I.R.G.C.# Comments:

Revised 07/14/10; 04/16/14; 06/02/14; 12/17/15; 03/11/16 Initials ______

Read every question carefully prior to responding. Answer every question completely.

This application form is to be completed by the person who is applying for a license to be issued by the Iowa Racing and Gaming Commission. Return completed form to the same Racing and Gaming office where you will be licensed. You must be fingerprinted by the Racing and Gaming office when you return your completed application.

Sign both the Statement of Truth and the Release Authorization forms in the presence of a notary public and have your signatures notarized. (See pages 13 and 15 respectively).

All entries on this form must be typed or neatly printed except for initials and signatures. Each page of this form must be signed or initialed by you after completion in the space provided.

If you need additional space to answer any questions, use page 11. Be sure to indicate the number of the question you are answering if you use this additional space.

Initials ______

SECTION 1 APPLICANT INFORMATION

1. Full Name: First Middle Maiden Last

2. Home Address: Street City State Zip Code

3. Occupation: Business:

4. Home #: Work #: Cell #:

E-mail:

5. DOB: Birthplace: SSN:

6. Height: Weight: Eye Color: Sex:

7. Give any other names you have used or by which you have been known.

8. Name of Spouse: First Middle Maiden Last

9. DOB: SSN:

10. Of what country are you a citizen?

A. List: Place of Birth: City State Country B. If you are not a citizen of the United States list:

1. Port of Entry to the United States:

2. Name and address of sponsor upon your arrival:

Initials ______

3 11. If you are a naturalized citizen, provide the following information:

Petition Number Date Granted Court City/State of Court Certificate Number

12. If you are a legally authorized permanent resident alien, provide the “A” number from your alien registration card (I 151 or I 551).

13. If you do not have an alien registration card but are an alien authorized to be employed in the United States, please provide the “A” number from that authorization.

14. Have you lived at your current address for less than three (3) years? Yes No

If you answered “yes” to this question, complete the chart below indicating all of your residences during the past three (3) years, except your current residence.

Dates Address From To Name, Address & Telephone Mo. Yr. Mo. Yr. (No., Street, Apt., City, County No. of Landlord or Mortgage & State) Own/Rent holder, if any

15. Have you ever before applied to the Iowa Racing and Gaming Commission for any license, permit, approval or registration? Yes No

If yes, complete the following: Type of License, Permit Date Application Disposition (Granted, If Issued License(s), give Approval or Registration was filed Pending, Denied) License Number(s) previously applied for

16. Have you ever applied in any jurisdiction for a license, permit or other authorization to participate in a lawful gambling operation (including casino gaming, horse racing, dog racing, pari-mutuel operation, lottery, sports betting, etc.)? Yes No

If yes, complete the following:

Type of Gambling Position Licensing Agency Disposition (granted, If issued Operation Sought or Held (including State, pending, denied) License(s), give County or License Municipality) number(s)

Initials ______

4 17. Employment History: List the last jobs you have had in the past five (5) years, beginning with the most recent and work backwards. Note with an asterisk (*) any employment where gaming was conducted on the premises.

Dates Name and Address Positions or Name of Reason for From To of Employer Duties Supervisor leaving

Initials ______5

18. For the purpose of this question, the word “arrest” includes any detaining, holding or taking into custody by any police or other law enforcement authority in order to answer for the alleged performance of any “offense” in this or any other state or foreign country; the word “charge” includes any indictment, complaint, information, summons, or other notice of the alleged commission of any “offense” in this or any other state or foreign country; and the word “offense” includes all misdemeanors, disorderly persons offenses and juvenile violations.

Have you ever been arrested or charged, even if not convicted, with any felony, misdemeanor, disorderly persons offense, juvenile offense or other offense, in Iowa or anywhere else? Yes No

If yes, complete the following:

Type of Charge or Name and Address of Disposition Date of Sentence Arrest and Date Government Agency or (Convicted, Disposition Received Court Involved Acquitted, Dismissed, Pending)

19. Are you currently on probation or parole as a result of any charge listed above? Yes No

If yes, for which charge?

When is your court supervision schedule to be completed?

Initials ______

20. List the name, address, occupation and telephone numbers of three references who have known you

well during the past five (5) years. (Do not list relatives or business associates).

20-1 Complete Name: First Middle Last

Approximate age: Occupation # Years Acquainted: :

Home Address: Street City State Zip Code

Business Address: Street City State Zip Code

Home #: Business #: Cell #:

20-2 Complete Name: First Middle Last

Approximate age: Occupation # Years Acquainted: :

Home Address: Street City State Zip Code

Business Address: Street City State Zip Code

Home #: Business #: Cell #:

20-3 Complete Name: First Middle Last

Approximate age: Occupation # Years Acquainted: :

Home Address: Street City State Zip Code

Business Address: Street City State Zip Code

Home #: Business #: Cell #:

Initials ______7

SECTION 2 MILITARY SERVICE DATA

21. Have you ever served in a military organization of the United States or been an active or inactive member of the Reserve Forces of the United States? Yes No . If yes, provide the information listed below.

Branch of Service:

Service Serial #: Highest Rank Held:

Period(s) of Active Service:

From To From To

22. Have you ever served in a military organization of a foreign government? Yes No . If yes, provide the information listed below:

Country: Branch of Service:

Service Serial #: Highest Rank Held:

Period(s) of Active Service:

From To From To

23. What is the type of your discharge or separation from military service? (Honorable, Dishonorable, Honorable Conditions, Medical, etc.)

24. Were you ever court martialed, tried on charges, or the subject of a summary court, desk court, captain’s mast, company punishment, or the subject of any disciplinary action while in military service? Yes No . If yes, give details of the charges and their disposition.

Initials ______

8 SECTION 3 MOTOR VEHICLE DATA

25. Complete the following as to all motor vehicles currently registered to you or your spouse.

Year Make & Model License Number and Registered Owner Expiration Date of State of Registry Registration

26. List all current motor vehicle driver’s licenses issued to you by this state or any other jurisdiction.

Date Issued License Number Type of License Jurisdiction Expiration Date Issuing License of License

Initials ______

FINANCIAL DATA

PERSONAL

27. Do you have any court-ordered child support obligations? Yes No

If yes, are you current with those payments? Yes No

28. Do you have any unpaid criminal citations or fines, including traffic violations? Yes No

29. Have you been a party to any civil litigation? Yes No

30. If you were the defendant in a civil case, do you have any overdue court-ordered obligations as a result of the case? Yes No

31. Do you have any outstanding student loans, backed by state or federal governments that are currently in repayment status? (i.e. Direct loans, Perkins loans, etc.) Yes No

If yes, are you current in those payments? Yes No

32. TAX DATA

STATE

Have you filed your state of residence income tax returns for the previous three (3) years? Yes No .

If no, have you filed for an extension? Yes No .

If no, explain:

STATE REVENUE DEPARTMENT ADDRESS:

FEDERAL

Have you filed your federal income tax return for the previous three (3) years? Yes No .

If no, have you filed for an extension? Yes No .

If no, explain:

IRS OFFICE LOCATION:

Initials ______

USE THIS PAGE FOR ADDITIONAL INFORMATION. BE SURE TO INDICATE THE NUMBER OF THE QUESTION YOU ARE ANSWERING.

Initials ______

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STATEMENT OF TRUTH

(TO BE COMPLETED IN THE PRESENCE OF A NOTARY PUBLIC)

STATE OF : : SS COUNTY OF :

______, being duly sworn according to law deposes and says: (NAME OF APPLICANT)

(Place your initials in appropriate response.)

1. I am the applicant who is submitting this application form. Yes No

2. I personally supplied the information contained in this form. Yes No

3. I swear (or affirm) that the information contained in this form is true to the best of my knowledge and belief. Yes No

______(LEGAL SIGNATURE OF APPLICANT) DATE

Subscribed and sworn to before me on this ______day of ______.

Notary Public State

Initials ______13

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STATE OF IOWA

AUTHORIZATION FOR EXAMINATION AND RELEASE OF INFORMATION

(TO BE COMPLETED IN THE PRESENCE OF A NOTARY PUBLIC)

I, ______, do hereby authorize a review, full disclosure and release of any and all records concerning myself to any duly authorized officer, agent or employee of the Iowa Division of Criminal Investigation, and/or the Iowa Racing and Gaming Commission, whether the records are of a public, private or confidential nature, including criminal history, with the following understandings:

1. The information reviewed, disclosed, or released may be used by the State of Iowa to conduct a thorough background investigation regarding me or my business entity and for any other lawful purpose.

2. I release the providers and users of the information collected pursuant to this authorization from any liability under state or federal privacy laws and further release the State of Iowa, its officers, agents and employees from any liability which may be incurred as a result of the collections and use of the information.

3. If this authorization is not sufficient to obtain access to certain records, it is understood that I may be requested to execute some other appropriate authorization or release, and that any failure to do so may be taken into consideration by the Iowa Racing and Gaming Commission and/or the Division of Criminal Investigation in their review of this application.

4. I understand that I may revoke this Authorization in writing at any time and the Iowa Racing and Gaming Commission and/or the Division of Criminal Investigation may take any such revocation of this Authorization into consideration in completing this background investigation.

5. This authorization will automatically expire one year from the date it is signed.

6. A photocopy of this Authorization will have the same force and effect as the original.

DATE: SIGNATURE:

APPLICANT’S NAME: (Typed or Printed)

Notary Public State

Initials ______

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STATE OF IOWA

CREDIT HISTORY DISCLOSURE AUTHORIZATION AND CONSENT FORM

PLEASE READ CAREFULLY

DISCLOSURE This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in Section 604 (b) to the applicant that a credit history check may be obtained for the purpose of this employment/licensing application. By the signature below, the applicant acknowledges that the Iowa Department of Public Safety, Division of Criminal Investigation and AccuSource, Inc. have made this disclosure.

APPLICANT AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION This release and authorization acknowledges that Iowa Division of Criminal Investigation may now, or any time while I am employed/licensed, conduct a verification of my credit history to fulfill the job and/or licensing requirements. The results of this verification process will be used to determine employment/ licensing eligibility for the position/license applied for. In the event that information from the report is utilized in whole or in part in making an adverse action decision with regard to your potential employment/ licensing, before making the adverse decision, we will provide you with a copy of the consumer report and a description in writing of your rights under the law. I authorize AccuSource, Inc. at 1240 E. Ontario Avenue, Suite 102-140, Corona, California 92881, 951-734- 8882, [email protected], www.accusource-online.com, and any of its agents, to disclose orally and in writing the results of this verification process to the designated authorized representative Iowa Division of Criminal Investigation. Contact AccuSource, Inc., if you want to receive a copy of our Information Security Policy.

I have read and understand this disclosure, and I authorize the credit history verification. I authorize persons and other organizations and Agencies to provide AccuSource, Inc. with all information that may be requested. I agree that any copy of this document is as valid as the original. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment/licensing was denied based on information obtained through the credit history verification process.

CONFIDENTIAL INFORMATION FOR POSITIVE IDENTIFICATION PURPOSES ONLY

Applicant Last Name First Name Middle Name

List Other Names Used Date of Birth (For Identification only) Social Security Number

Current Address City/State/Zip Dates

Previous Address City/State/Zip Dates

 RELEASE MUST BE SIGNED Applicant’s Signature Today’s Date

□ I understand my credit report will be pulled from TransUnion and wish to receive a copy of the Credit Report from TransUnion directly. (California, Oklahoma, Minnesota residents only).

Initials ______17 PAGE INTENTIONALLY

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18 Request for Transcript of Tax Return Form 4506-T Do not sign this form unless all applicable lines have been completed. (July 2017) OMB No. 1545-1872 Department of the Request may be rejected if the form is incomplete or illegible. Treasury For more information about Form 4506-T, visit www.irs.gov/form4506t. Internal Revenue Service Tip. Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on “Get a Tax Transcript…” under “Tools” or call 1-800-908-9946. If you need a copy of your return, use Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return. 1a Name shown on tax return. If a joint return, enter the name 1b First social security number on tax return, individual taxpayer identification shown first. number, or employer identification number (see instructions)

2a If a joint return, enter spouse’s name shown on tax return. 2b Second social security number or individual taxpayer Identification number if joint tax return

3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)

4 Previous address shown on the last return filed if different from line 3 (see instructions)

5 If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address, and telephone number. Iowa Division of Criminal Investigation 215 East 7th Street, Des Moines, Iowa 50319 Fax: 515-725-6035 Participant: 0000302214 heldenbr Caution. If the tax transcript is being mailed to a third party, ensure that you have filled in lines 6 through 9 before signing. Sign and date the form once you have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax transcript to the third party listed on line 5, the IRS has no control over what the third party does with the information. If you would like to limit the third party’s authority to disclose your transcript information, you can specify this limitation in your written agreement with the third party. 6 Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form number per request. 1040 a Return Transcript, which includes most of the line items of a tax return as filed with the IRS. A tax return transcript does not reflect changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series, Form 1065, Form 1120, Form 1120-A, Form 1120-H, Form 1120-L, and Form 1120S. Return transcripts are available for the current year and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days ......

b Account transcript, which contains information on the financial status of the account, such as payments made on the account, penalty assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 10 business days . c Record of Account, which provides the most detailed information as it is a combination of the Return Transcript and the Account Transcript. Available for current year and 3 prior tax years. Most requests will be processed within 10 business days . . . . . 7 Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available after June 15th. There are no availability restrictions on prior year requests. Most requests will be processed within 10 business days . . 8 Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS. For example, W-2 information for 2011, filed in 2012, will likely not be available from the IRS until 2013. If you need W-2 information for retirement purposes, you should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 10 business days . . Caution. If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed with your return, you must use Form 4506 and request a copy of your return, which includes all attachments. 9 Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter each quarter or tax period separately. / N/A / 12 / 31 / 2014 12 / 31 / 2015 12 / 31 / 2016

Caution: Do not sign this form unless all applicable lines have been completed. Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax information requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506-T on behalf of the taxpayer. Note. This form must be received by IRS within 120 days of the signature date.

Signatory attests that he/she has read the attestation clause and upon so reading declares that he/she Phone number of taxpayer on line 1a has the authority to sign the Form 45-06-T. See instructions. or 2a

Signature (see instructions) Date

Sign Here Title (if line 1a above is a corporation, partnership, estate, or trust)

Spouse’s signature Date For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 37667N Form 4506-T (Rev. 7-2017) Form 4506-T (Rev. 7-2017) Page 2 Section references are to the Internal Revenue Code If you lived in any officer or employee on written request by any unless otherwise noted. or your business Mail or fax to: principal officer and attested to by the secretary or other officer. A bona fide shareholder of record Future Developments was in: owning 1 percent or more of the outstanding stock For the latest information about Form 4506-T and its Alabama, Alaska, of the corporation may submit a Form 4506-T but instructions, go to www.irs.gov/form4506t. Arizona, Arkansas, must provide documentation to support the Information about any recent developments affecting California, Colorado, requester’s right to receive the information. Form 4506-T (such as legislation enacted after we Florida, Hawaii, Idaho, Partnerships. Generally, Form 4506-T can be released it) will be posted on that page. Iowa, Kansas, Louisiana, Minnesota, signed by any person who was a member of the Mississippi, Internal Revenue Service partnership during any part of the tax period General Instructions requested on line 9. Caution: Do not sign this form unless all applicable Missouri, Montana, RAIVS Team lines have been completed. Nebraska, Nevada, P.O. Box 9941 All others. See section 6103(e) if the taxpayer has New Mexico, Mail Stop 6734 died, is insolvent, is a dissolved corporation, or if a Purpose of form. Use Form 4506-T to request tax North Dakota, Ogden, UT 84409 trustee, guardian, executor, receiver, or return information. You can also designate (on line 5) Oklahoma, Oregon, administrator is acting for the taxpayer. a third party to receive the information. Taxpayers South Dakota, Texas, Note: If you are Heir at law, Next of kin, or using a tax year beginning in one calendar year and Utah, Washington, Beneficiary you must be able to establish a material ending in the following year (fiscal tax year) must file Wyoming, a foreign interest in the estate or trust. Form 4506-T to request a return transcript. country, American 801-620-6922 Samoa, Puerto Rico, Documentation. For entities other than individuals, Note: If you are unsure of which type of transcript Guam, the you must attach the authorization document. For you need, request the Record of Account, as it Commonwealth of the example, this could be the letter from the principal provides the most detailed information. Northern Mariana officer authorizing an employee of the corporation or Islands, the U.S. Virgin the letters testamentary authorizing an individual to Tip: Use Form 4506, Request for Copy of Islands, or A.P.O. or act for an estate. Tax Return, to request copies of tax returns. F.P.O. address Signature by a representative. A representative Connecticut, can sign Form 4506-T for a taxpayer only if the Automated transcript request. You can quickly Delaware, District of taxpayer has specifically delegated this authority to request transcripts by using our automated Columbia, Georgia, the representative on Form 2848, line 5. The self-help service tools. Please visit us at IRS.gov and Illinois, Indiana, Internal Revenue Service representative must attach Form 2848 showing the click on “Get a Tax Transcript…” under “Tools” or Kentucky, Maine, RAIVS Team delegation to Form 4506-T. call 1-800-908-9946. Maryland, P.O. Box 145500 Massachusetts, Stop 2800 F Privacy Act and Paperwork Reduction Act Notice. Where to file. Mail or fax Form 4506-T to Michigan, New Cincinnati, OH 45250 We ask for the information on this form to establish the address below for the state you lived in, Hampshire, New your right to gain access to the requested tax or the state your business was in, when that return Jersey, New York, information under the Internal Revenue Code. We was filed. There are two address charts: one for North Carolina, need this information to properly identify the tax individual transcripts (Form 1040 series and Form Ohio, Pennsylvania, information and respond to your request. You are W-2) and one for all other transcripts. Rhode Island, South not required to request any transcript; if you do Carolina, Tennessee, 859-669-3592 request a transcript, sections 6103 and 6109 and If you are requesting more than one transcript or Vermont, Virginia, their regulations require you to provide this other product and the chart below shows two West Virginia, information, including your SSN or EIN. If you do not different addresses, send your request to the Wisconsin provide this information, we may not be able to address based on the address of your most recent process your request. Providing false or fraudulent return. Line 1b. Enter your employer identification number information may subject you to penalties. (EIN) if your request relates to a business return. Otherwise, enter the first social security number Routine uses of this information include giving it to Chart for individual transcripts (SSN) or your individual taxpayer identification the Department of Justice for civil and criminal (Form 1040 series and Form W-2 number (ITIN) shown on the return. For example, if litigation, and cities, states, the District of Columbia, and U.S. commonwealths and possessions for use and Form 1099) you are requesting Form 1040 that includes Schedule C (Form 1040), enter your SSN. in administering their tax laws. We may also disclose this information to other countries under a tax treaty, If you filed an Line 3. Enter your current address. If you use a P.O. to federal and state agencies to enforce federal individual return Mail or fax to: box, include it on this line. nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. and lived in: Line 4. Enter the address shown on the last return Alabama, Kentucky, filed if different from the address entered on line 3. You are not required to provide the information Louisiana, Mississippi, requested on a form that is subject to the Paperwork Note: If the addresses on lines 3 and 4 are different Tennessee, Texas, a Internal Revenue Service Reduction Act unless the form displays a valid OMB and you have not changed your address with the foreign country, American RAIVS Team control number. Books or records relating to a form IRS, file Form 8822, Change of Address. For a Samoa, Puerto Rico, Stop 6716 AUSC or its instructions must be retained as long as their business address, file Form 8822-B, Change of Guam, the Austin, TX 73301 contents may become material in the administration Address or Responsible Party – Business. Commonwealth of the of any Internal Revenue law. Generally, tax returns Northern Mariana Islands, Line 6. Enter only one tax form number per and return information are confidential, as required the U.S. Virgin Islands, or 512-460-2272 request. by section 6103. A.P.O. or F.P.O. address Signature and date. Form 4506-T must be signed The time needed to complete and file Form Alaska, Arizona, Arkansas, and dated by the taxpayer listed on line 1a or 2a. If you 4506-T will vary depending on individual California, Colorado, completed line 5 requesting the information be circumstances. The estimated average time is: Hawaii, Idaho, Illinois, Internal Revenue Service sent to a third party, the IRS must receive Form Learning about the law or the form, 10 min.; Indiana, Iowa, Kansas, RAIVS Team 4506-T within 120 days of the date signed by the Preparing the form, 12 min.; and Copying, Michigan, Minnesota, Stop 37106 taxpayer or it will be rejected. Ensure that all assembling, and sending the form to the IRS, Montana, Nebraska, Fresno, CA 93888 applicable lines are completed before signing. 20 min. Nevada, New Mexico, North Dakota, Oklahoma, If you have comments concerning the accuracy of You must check the box in the signature these time estimates or suggestions for making Oregon, South Dakota, area to acknowledge you have the Utah, Washington, Form 4506-T simpler, we would be happy to hear 559-456-7227 authority to sign and request the from you. You can write to: Wisconsin, Wyoming information. The form will not be Connecticut, Delaware, processed and returned to you if the Internal Revenue Service District of Columbia, box is unchecked. Tax Forms and Publications Division Florida, Georgia, Maine, Internal Revenue Service 1111 Constitution Ave. NW, IR-6526 Maryland, Massachusetts, RAIVS Team Individuals. Transcripts of jointly filed tax returns Washington, DC 20224 Missouri, New Hampshire, Stop 6705P-6 Kansas City, Mo 64999 may be furnished to either spouse. Only one Do not send the form to this address. Instead, see New Jersey, New York, signature is required. Sign Form 4506-T exactly as Where to file on this page. North Carolina, Ohio, your name appeared on the original return. If you Pennsylvania, Rhode changed your name, also sign your current name. Island, South Carolina, Vermont, Virginia, West 816-292-6102 Corporations. Generally, Form 4506-T can be Virginia signed by: (1) an officer having legal authority to bind the corporation, (2) any person designated by the Chart for all other transcripts board of directors or other governing body, or (3)