Illinois State Seal
Illinois Gaming Board  
Video Gaming Location License Application  


9. DISCLOSURE OF RECORDS ("5.1 Information")


Section 80 of the Video Gaming Act provides, in part, that the provisions of the Illinois Gambling Act shall apply to the Video Gaming Act. 230 ILCS 40/80. Section 5.1 of the Illinois Gambling Act sets forth certain information regarding each applicant or licensee that the Board will make available to any person upon written request. 230 ILCS 10/5.1. The "5.1 Information" regarding applicants and licensees under the Video Gaming Act will also be made available upon written request.
Accordingly,
ALL APPLICANTS FOR LICENSURE MUST PROVIDE THE FOLLOWING INFORMATION, WHICH WILL BE PUBLICLY AVAILABLE TO ANYONE WHO REQUESTS IT.



1. The name, business address and business telephone number of any applicant or licensee.
2. An identification of any applicant or licensee including, if an applicant or licensee is not an individual, the names and addresses of all stockholders and directors, if the entity is a corporation; the names and addresses of all members, if the entity is a limited liability company; the names and addresses of all partners, both general and limited, if the entity is a partnership; and the names and addresses of all beneficiaries, if the entity is a trust. If an applicant or licensee has a pending registration statement filed with the Securities and Exchange Commission, only the names of those persons or entities holding interest of 5% or more must be provided.
3. An identification of any business, including, if applicable, the state of incorporation or registration, in which an applicant or licensee or an applicant's or licensee's spouse or children has an equity interest of more than 1%. If an applicant or licensee is a corporation, partnership or other business entity, the applicant or licensee shall identify any other corporation, partnership or business entity in which it has an equity interest of 1% or more, including, if applicable, the state of incorporation or registration. This information need not be provided by a corporation, partnership or other business entity that has a pending registration statement filed with the Securities and Exchange Commission.
4. Whether an applicant or licensee has been indicted, convicted, pleaded guilty or nolo contendere, or forfeited bail concerning any criminal offense under the laws of any jurisdiction, either felony or misdemeanor (except for traffic violations), including the date, the name and location of the court, arresting agency and prosecuting agency, the case number, the offense, the disposition and the location and length of incarceration.
5. Whether an applicant or licensee has had any license or certificate issued by a licensing authority in Illinois or any other jurisdiction denied, restricted, suspended, revoked or not renewed and a statement describing the facts and circumstances concerning the denial, restriction, suspension, revocation or non-renewal, including the licensing authority, the date each such action was taken, and the reason for each such action.
6. Whether an applicant or licensee has ever filed or had filed against it a proceeding in bankruptcy or has ever been involved in any formal process to adjust, defer, suspend or otherwise work out the payment of any debt including the date of filing, the name and location of the court, the case and number of the disposition.
7. Whether an applicant or licensee has filed, or been served with a complaint or other notice filed with any public body, regarding the delinquency in the payment of, or a dispute over the filings concerning the payment of, any tax required under federal, State or local law, including the amount, type of tax, the taxing agency and time periods involved.
8. A statement listing the names and titles of all public officials or officers of any unit of government, and relatives of said public officials or officers who, directly or indirectly, own any financial interest in, have any beneficial interest in, are the creditors of or hold any debt instrument issued by, or hold or have any interest in any contractual or service relationship with, an applicant or licensee.
9. Whether an applicant or licensee has made, directly or indirectly, any political contribution, or any loans, donations or other payments, to any candidate or office holder, within 5 years from the date of filing the application, including the amount and the method of payment.
10. The name and business telephone number of the counsel representing an applicant or licensee in matters before the Board.
(Paragraphs 11 and 12 below have been modified to provide
information applicable for video gaming.)

11. A description of any proposed or approved gambling operation, including the type of boat, home dock, or casino or gaming location, expected economic benefit to the community, anticipated or actual number of employees, any statement from an applicant or licensee regarding compliance with federal and State affirmative action guidelines, projected or actual admissions and projected or actual adjusted gross gaming receipts.
12. A description of the product or service to be supplied by an applicant for a supplier's license.

Disclosure of Records will not be submitted to the IGB until you submit the application on page 10. A pdf of your disclosure is also available on page 10.

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