Embed Size (px)
Citation preview
COPY FOR PUBLIC FILE
J.D. SHORE FINANCIAL LLC
# W % , Pennsylvania j,,f\ Gaming ^# Control
Board € /
PRINCIPAL ENTITY FORM
• - . - . - ,
COPY FOR PUBLIC FILE
INSTRUCTIONS
PENNSYLVANIA GAMING IS GOVERNED BY THE LAWS SET FORTH.IN 4 P A . C : S . PART II, ENACTED BY THE ACT OF JULY 5, 2004 {P.L. 572, No. 71) THE PENNSYLVANIA RACE HORSE DEVELOPMENT AND GAMING ACT (ACT) AS AMENDED AND 58 P A . CODE PART VII. GAMING CONTROL BOARD (REGULATIONS).
AN APPLICATION THAT HAS BEEN ACCEPTED FOR FlLlNG AND ALL RELATED MATERIALS SUBMITTED TO THE PENNSYLVANIA GAMING CONTROL BOARD ("BOARD") SHALL.BECOME THE PROPERTY OF THEBOARD Af^D WILL NOT BE RETURNED TO THE APPLICANT:
UNLESS OTHERWISE PROVIDED FOR IN THE GAMING ACT AND'REGULATIONS, EACH PRINCIPAL; PERSON WITH
CONTROLLING,INTEREST; INSTITUTIONAL INVESTOR AND/INANCIAL.BACKER WHO IS AN ENTITY MUST COMPLETE-THE PRINCIPAL ENTITY FORM OR THERRINCIPAL WAIVER FORM - ENTITY".
PRINCIPAL - 4 PA.C^.S. §1103 DEFINESPRINCIPAL AS "AN OFFICER; DIRECTOR; PERSON WHO DIRECTLY HOLDS A
BENEFICIAL INTEREST. IN OR OWNERSHIP OF THE SECURITIES OF AN APPLICANT OR LICENSEE; PERSON WHO HAS A
CONTROLLING INTEREST IN AN APPLICANT OR LICENSEE; OR HAS THE ABILITY TO ELECT A MAJORITY OF THE'BOARD OF DIRECTORS OF A LICENSEE OR TO OTHERWISE CONTROL A LICENSEE; LENDER OR OTHER LICENSED RNANCIAL INSTITUTION OF AN APPLICANT OR LICENSEE, OTHERTI-IAN A BANK OR LENDING.INSTITUTION WHICH MAKES A LOAN OR HOLDS A MORTGAGE OR OTHER LIEN ACQUIRED IN THE' ORDINARY COURSE OF.BUSINESS; UNDERVTOITER OF AN APPLICANT OR. LICENSEE; OR OTHER PERSON OR EMPLOYEE OF AN APPLICANT, SLOT MACHINE,LICENSEE,
MANUFACTURER LICENSEE OR'SUPPLIER LICENSEE DEEMED TO BE A PRINCIPAL BY THE, PENNSYLVANIA GAMING
CONTROL BOARD."
DIRECTOR - BOARD REGULATIONS DEFINE DIRECTOR AS "A DIRECTOR OF A CORPORATION OR ANY PERSON
PERFORMING SIMILAR FUNCTIONS WITH RESPECT TO AN ENTITY, WHETHER INCORPORATED OR
UNINCORPORATED."
OFFICER - BOARD REGULATIONS D E R N E OFFICER AS "A PRESIDENT, CHIEF EXECUTIVE OFFICER, CHIEF
OPERATING OFFICER, SECRETARY; TREASURER. PRINCIPAL LEGAL OFFICER, PRINCIPAL COMPLIANCE OFFICER,
PRINCIPAL FINANCIAL OFF^LCER, COF^PTFIOLLER, PRINCIPAL ACCGUNTI"NG OFFICER,.CHIEF ENGINEER OR TECHNICAL
OFFICER OF-A MANUFACTURER„0R PRINCIPAL SLOT OPERATIONS.OFFICER OF A'SLOT FMCHINE LICENSEE AND ANY
PERSON ROUTINELY PERFORMING CORRESPONDING FUNCTIONS WITH RESPECT TO AN ENTITY "WHETHER
INCORPORATED OR UNINCORPORATED:"
KEY EMPLOYEE '- 58 PA. C O D E §40lA:3'DEFir^ES KEY EMPLOYEE AS "ANY INDIVIDUAL V M O IS: (i) EMPLOYED IN A
DIRECTOR OR DEPARTMENT HEAD CAPACITY AND'WHO IS EMPOWERED TO MAKE DISCRETIONARY DECISIONS THAT REGULATE SLOT MACHINE OPERATIONS: IN THIS COMMONWEALTH, INCLUDING THE GENERAL MANAGER AND ASSISTANT MAf AGER OF THE LICENSED FACILITY, DIRECTOR OF SLOT OPERATIONS, DIRECTOR OF CAGE AND CREDIT OPERATIONS, DIRECTOR OF SURVEILLANCE, DIRECTOR OF MARKETING, DIRECTOR OF f lANAGEMENT INFORMATION SYSTEMS, DIRECTOR OF SECURITY, CCtf /IPTROLLER AND ANY EfvlPLOYEE WHO SUPERVISES THE OPERATIONS OF THESE DEPARTMENTS OR TO WHOM THESE DEPARTMENT DIRECTORS OR DEPARTMENT HEADS REPORT; (11) EMPLOYED BY A SLOT MACHINE LICENSEE OR APPLICANT, MANUFACTURER LICENSEE OR APPLICANT, SUPPLIER LICENSEE OR APPLICANT, CERTIFIED VENDOR OR APPLICANT OR LICENSED JUNKET ENTERPRISE VVHOSE DUTIES AFFECT OR REQUIRE CONTACT WITH SLOT MACHINES, SLOT MONITORING SYSTEMS, CASINO MANAGEMENT SYSTEMS. PLAYER TRACKING SYSTEMS AND WIDE- AREA PROGRESSIVE SYSTEMS FOR USE, OR PLAY IN THE COf.1MONWEALTH, WHETHER OR NOT THE INDIVIDUAI. IS, ASSIGNED. TO GAMING OPERATIONS IN THE COMMONWEALTH AND (lll)':OTHER POSITIONS WHICH THE BOARD VVILL DETERMINE BASED ON DETAILED ANALYSES OF JOB DESCRIPTIONS AS PROVIDED IN THE INTERNAL CONTROLS,OF THE APPLICANT OR-LICENSEE AS APPROVED BY THE BOARD UNDER § 1 3 2 2 ( C ) OF THE ACT(RELAT1NG TO SLOT MACHJNE ACCOUNTING CONTROLS AND AUDITS).
ALL OTHER GAMING EMPLOYEES UNLESS OTHERWISE DESIGNATED BY THE BOARD, WILL DECLASSIFIED AS NON-
KEY EMPLOYEES,*
CONTROLLING INTEREST - 4 PA.C.S, §1103 DEF^INES'CONTROLLING INTEREST AS "FOR A PUBLICLY TRADED
DOMESTIC OR FOREIGN CORPORATION,. A CONTROLUNG INTEREST IS AN INTEREST IN A LEGAL ENTITY; APPLICANT^
OR.LICENSEE IF= A PERSON'S SOLE VOTING RIGHTS UNDER.STATE LAW OR CORPORATE OR-CORPORATE AR'Jjat^"'\
PGCB^PE-loVl i Initial ^ N % J ^
COPY FOR PUBLIC FILE
OR BYLAWS ENTITLE THE PERSON TO ELECT OR APPOINT ONE OR MORE OF THE MEMBERS,OF THE.BOARD OF DIRECTORS OR OTHER GOVERNING BOARD OR THE CWNERSHIP OR BENEFICIAL HOLDING OF 5% OR MORE OF THE SECURITIES OF THE PUBLICLY TRADED CORPORATION, PARTNERSHIP, LIMITED .LIABILITY COMPANY OR OTHER FORM OF PUBLICLY TRADED LEGAL ENTITY, UNLESS THIS PRESUMPTION OF CONTROL 0R',ABIL1TY TO ELECT IS REBUTTED BY CLEAR AND CONVINCING EVIDENCE. FOR A PRIVATELY HELD DOMESTIC OR FOREIGN CORPORATION, PARTNERSHIP, LIMITED LIABILITY COMPANY OR OTHER FORM OF PRIVATELY HELD LEGAL ENTITY, A CpNTROLLING'lNTEREST IS THE HOLDING OF SECURITIES IN THE LEGAL ENTITY, UNLESS THIS PFIESUMPTION OF CONTROL IS REBUTTED BY CLEAR AND CONVINCING EVIDENCE."
INDIRECT OWNERSHIP INTEREST - BOARD REGULATIONS DEFINE INDIRECT OWNERSHIP INTEREST AS "AN OWNERSHIP INTEREST IN AN^ENTITY THAT HAS A DIRECT OWNERSHIP INTEREST IN AN APPLICANT OR LICENSEE, OR A DIRECT OWNERSHIP INTERESTIN AN ENTITY THATHAS AN OWNERSHIPINTEREST IN AN APPLICANT OR LICENSEE THROUGH O N E OR MORE INTERVENING ENTITIES."
PUBLICLY TRADED CORPORATION - 4 PA. CODE §1103 DEFINES PUBLICLY TRADED CORPOFWTION A S "A
PERSON, OTHER THAN AN INDIVIDUAL, WHICH:
( 1 ) HAS A CLASS OR SERIES OF SECURITIES REGISTEREDUNDER THE SECURITIES EXCHANGE A C T
OF 1934 (48 STAT, 881, 15 U.S,C:'78AETSEO.);
(2) IS A REGISTERED MANAGEMENT COMPANYUNDER THE INVESTMENT COMPANY ACT OF 1940 (54 STAT. 7 8 9 , 1 5 U ; S , C . 8 0 A - 1 E T S E O , ) ; O R
(3 ) IS SUBJECT TO THE REPORTING OBLIGATIONS IMPOSED BY SECTION 15(D) OF THE SECURITIES
EXCHANGE A C T OF 1934 BY REASON OF HAVING FILED A REGISTRATION STATEMENT WHICH HAS BECOME
EFFECTIVE UNDER THE SECURITIES ACT OF 1933 (48 STAT. 74, 15 U.S.C. 7 7 A ET SEQ.)."
E N T I T Y - BOARD REGULATIONS D E R N E ENTITY AS "A PERSON, OTHER THAN AN INDIVIDU/M.."
INDIVIDUAL - BOARD REGULATIONS DEFINE AN INDIVIDUAL AS "A NATURAL PERSON."
UNDERWRITER - 4^ PA, CODE § 1103 DEFINES UNDERV^ITER "AS DEFINED IN THE ACT OF DECEMBER 5,, 1972
(P.L. 1280, NO. 284). KNOWN AS THE PENNSYLVANIA SECURITIES A C T OF 1972."
INSTITUTIONAL INVESTOR -• 58 PA. CODE §4aTA.3 DEFINES AN INSTITUTIONAL INVESTOR AS 'ARETIREMENT FUND
ADMINISTERED BY PUBLIC AGENCY FOR THE EXCLUSIVE BENEFIT OF FEDERAL, STATE OR LOCAL PUBLIC EMPL0YEES,,INVESTMENT COMPANY REGISTERED UNDER THE INVESTMENT COMPANY ACT OF 1940 (15 U.S,C.A. §§ 80A-1.- 30A-64), CO'LLECT^/E INVESTMENT TRUST ORGANIZED BY BANKS UNDER PART NINE OF THE RULES OF THE COMPTROLLER OF THE CURRENCY, CLOSED END INVESTMENT TRUST, CHARTERED OR LICENSED LIFE
INSURANCE COMPANY OR PROPERTY AND CASUALTY INSURANCE'COMPANY, BANKING AND OTHER CHARTERED OR LICENSED LENDING INSTITUTION, INVESTMENT ADVISOR REGISTERED VNDER THE INVESTMENT ADVISORS ACT OF 1940 (15 U.S.C.A. §§ 80B-1 - 80B-21), AND SUCH OTHER- PERSONS AS THE BOARD MAY DETERMINE CONSISTENT WITH THIS PART.-"
PRIVATE INVESTMENT F U N D - BOARD REGULATIONS DEFINE PRIVATE INVESTMENT FUND AS "AN ENTPTY THAT
MEETS'THE DEFINITION OF "INVESTMENT COMPANY" UNDER SECTION 3 ( A ) ( 1 ) OF THE INVESTMENT COMPANY A C T
OF 1940 (15 U.S.C. 8 0 A - 3 ( A ) ( 1 ) ) , BUT IS OTHERWISE EXEMPT FROM THE DEFINITION OF "INVESTMENT COMPANY" UNDER SECTION 3 ( C ) ( 7 ) OF THE IWESTMENT COMPANY AcTOF 1940 (15 U . S . C . 8 0 A - 3 (c)(7)):
REGISTERED INVESTMENT COMPANY - BOARD REGULATIONS DEFINE A REGISTERED INVESTMENT COMPANY AS
"AN INVESTMENT (IOMPANY THAT HAS REGISTERED WITH THE S E C PURSUANT TO THE INVESTMENT COMPANY ACT
OF 1940."
PGCB-PE-lOn Initials
c o p y FOR PUBLIC FILE
REGISTERED iNVESTMEfJT ADVISER - BOARD REGULATIONS DEFINEJREGISTERED'INVESTMENT, ADVISER AS "AN INVESTMENT ADVISER THAT HAS REGISTERED WITH THE SEC'PURSUANT TO THE'INVESTMENT ADVISERS ACT OF 1940'."
LENDING INSTITUTION - BOARD REGULATIONS DEFINE A LENDING INSTITUTION AS "A PERSON WHO HAS BEEN ISSUED-A LICENSE TO LEND .MONEY BY A STATE OR FEDERAL AGENCY OR A PERSON WHO SATISFIES THE DEFINITION OF "QUALIFIED INSTITUTIONAL BUYER' PURSUANT TO 17 C. F.R. § 230.144A':' ,
AFF IUATE, AFRLIATE OF OR PERSON AFFIUATEO WITH - 4 P A . C . S , § 1103 DEFINES AFRLIATE, AFFILIATE OF OR PERSON AFFILIATED WITH AS "A PERSON THAT DIRECTLY OR'- INDIRECTLY. THROUGH ONE OR MORE INTEF^EDLARIES, CONTROLS. IS CONTROLLED BY OR IS UNDER COMMON CONTROLWITH A SRECIRED PERSON."
PRINCIPAL AFFIUATE - BOARD; REGULATIONS DERNE PRINCIPAL AFFILIATE AS "AN INTERMEDIARY OR HOLDING COMPANY OF AN APPLICANT OR LICENSEE."
PRINCIPAL ENTITY - BOARD REGULATIONS DEFINE PRINCIPAL ENTITY-AS "AN ENTITY THAT MEETS THE DEFINITION OF PRINCIPAL IN SECTION 1103 OF THE ACT (RELATING TO DEFINITIONS) OR IS OTHERWISE REQUIRED TO BE LICENSED AS A PRINCIPAL AND IS NOT AN INTERMEDIARY OR HOLDINGCOMPANY OF AN APPLICANT OR LICENSEE."
SUBSIDIARY - 4 PA.C.S. § 1103 DEFINES'SUBSIDIARY AS "A PERSON OTHER THAN AN,INDIVIDUAL, THE TERM
INCLUDES:
( 1 ) A CORPORATION. ANY SIGNIFICANT PART OF WHOSE OUTSTANDING EQUITY SECURITIES ARE OWNED, SUBJECT TO A POV/ER OR RIGHT OF CONTROL, OR HELD.WITH POWER TO VOTE, BY A HOLDING COMPANY OR AN INTERMEDIARY COMPANY;
(2) A SIGNIFICANT INTEREST IN A PERSON, OTHER THAN AN INDIVIDUAL. WHICH IS OWNED, SUBJECT TO A POWER OR RIGHT OF CONTROL,. OR HELD WITH POWER TO VOTE, BY A HOLDING CC*-1PANY OR AN
'INTERMEDIARY COMPANY; OR
(3) A PERSON DEEMED TO BE A'SUBSIDIARY BY THE PENNSYLVANIA GAMING CONTROL BOARD."
lNTERMEDlARY-4 P A . C . S : §'1103.DEF^INES INTERMEDIARY AS "APER,S0N,OTHERTHAN AN INDIVIDUAL, VVHICH:
( 1 ) IS A HOLDING COMPANY WITH RESPECT TO A CORPORATION OR OTHER FORM OF BUSINESS ORGANIZATION, WHICH HOLDS OR APPUES FOR A LICENSE'UNDER THIS PARTJ-AND
(2) ISA SUBSIDIARY WITH RESPECT TO ANY HCS.DINGCOMPANY."
HOLDING COMPANY - BOARD REGULATIONS DEFINE HOLDING COMPANY AS "A F-ERSON, OTHER THAN AN INDIVIDUAL, WHICH, DIRECTLY OR INDIRECTLY, OWNS, HAS-THE POWER OR RIGHT TO CONTROL OR HAS THE PO'A/ER OR RIGHT TO VOTE 20% OR MORE OFTHE'OUTSTANDING'VOTING SECURITIES OF.A CORPORATION OR OTHER ENTITY. A HOLDING COMPANYTNDIRECTLY^HAS, HOLDS OR OWNS ANY.SUCH POWER, RIGHT OR SECURITY IF IT DOES SO THROUGH AN INTERESTIN A SUBSIDIARY OF SUCCESSIVE SUBSIDIARIES;"
VOTING SECURITY - BOARD REGULATIONS DEFINE VOTING SECURITY AS "A SECURITY OR OTHER INTEREST WHICH ENTITLES THE OWNER TO VOTE FOR THE ELECTION OF;
(i) A DIRECTOR OF A CORPORATION. (11) A PERSON PERFORMING FUNCTIONS SIMILAR TO,A DIRECTOR WITH RESPECT TO,AN ORGANIZATION
VJHETHER'INCORPORATED OR.UNINCORPORATED!"
FINANCIAL BACKER - 4 P A . C . S . §1103 DEFINES RNANCIAL BACKER AS "AN INVESTOR, MORTGAGEE, BONDHOLDER, NOTE HOLDER OR OTHER SOURCES OF EQUITY OR CAPITAL PROVIDED TO AN APPLIC/ LICENSED ENTITY." f ' ^ I
PGCB-PE-1Q11 i i i Initials'^
c o p y FOR PUBLIC FILE
UNLESS OTHERWISE PROVIDED FOR IN THE-GAMING ACT.AND REGULATIONS, EACH PRINCIPAL; KEY EMPLOYEE;
PERSONVyiTH C O N T R O L L I N G INTEREST; INSTITUTIONAL INVESTOR; UNDERWRITER AND FINANCIAL BACKER WHO IS
A NATURAL PERSON MUST COMPLETE A MULTI-JURISDICTIONAL P H D AND PA SUPPLEMENT OR ARRLNCLPALYKEY,
EMPLOYEE WAIVER.FORM. EACH PRINCIPAL; PERSON WITH CONTROLLING INTEREST; INSTITUTIONAL INVESTOR;
U N D E R V / R I T E R A N D F I N A N C I A L B A C K E R T H A T I S A N ENTtlY MUST COMf^LETE A PRINCIPAL .ENTITY FORM OR A PRINCIPAL V^AIVER FORM - ENTITY.
THE ORIGINAL FORM, ONE PAPER COPY, AND 0 N E ( 1 ) COMPACT DISC (CD) CONTAINING ALL FORMS MUST BE SENT
TO THE PENNSYLVANIA GAMING.OONTROL BOARD, BUREAU OF LICENSING; 303 WALNUT STREET. FIFTH FLOOR, VERIZON TOWER. HARRISBURG, PENNSYLVANIA, 17101 WITH THE.APPROPRIATE FEE: PLEASE REFER TO THE LICENSING SECTION OF THE BOARD'S WEBSITE FOR.CD FORI^ATTING REQUIREMENTS.
1. APPLICATION FEES
APPLICATION FEES MUST BE SUBMITTED WITH THE APPLICATION. THESE'FEES ARE NON-REFUNDABLE DEPOSITS THAT WILL BE USED BY THE BOARD TO PROCESS AND INVESTIGATE THE ENTITY RLING THE
FORM.
THERE,fJiAY BE-ADDITIONAL COSTS AND EXPENSES INCURRED-BY THE BOARD IN ITS PROCESSING AND
INVESTIGATION OF THE ENTITY FILING THE FORM, WJHICH MUST BE REIMBURSED TO THE BOARD,
FEES SHALL BE PAID BY MONEY ORDER ORCHECK MAIDE PAYABLE TO THE "PENNSYLVANIA GAMING CONTROL BOARD," CASH V^L'L NOT BE ACCEPTED BY THE BOARD.
PRINCIPAL ENTITY ;.. 52,500,00
2. APPLICATION FORM INSTRUCTIONS
A. GENERALLY
AS'USED IN THE PRINCIPAL ENTITY FORM, THE .WORDS "APPUCANT" AND-"YOU" SHALL MEAN THE
PRINCIPAL COMPLETING THIS PRINCIPAL ENTITY FORM.
AS USED IN THE PRINCIPAL ENTITY FORM, THE WORDS 'BUSINESS ENTITY" SHALL MEAN THE I M N U F A C T U R E R , MANIJFACTURER'S DESIGNEE, SUPPLIER, M A N A G E M E N T COMPANY, JUNKET
ENTERPRISE O R S L O T MACHINE APPLICANT OR UCENSEE OR ANY OF ITS AFFILIATES,
INTERMEDIARIES, SUBSIDIARIES OR HOLDING COMPANIES FOR WHICH YOU ARE A PRINCIPAL.
A L L ENTRIES O N THE FORM MUST BE'TYPED OR PRINTED-IN BLOCK LETTERING, INITIALS AND SIGNATURES MUST BE HANDWRITTEN BY THE PERSON PROVIDING THE INFORMATION, 1F THE ANSVVERS'ARE NOT LEGIBLE, THE APPLICATLON MAY NOT BE ACCEPTED,
READ EACH QUESTION CAREFULLY PRIOR TO ANSWERING. ANSWER EVERY QUESTION COMPLETELY, DO NO LEAVE BLANK;SPACES. 1F A OUESTION, SCHEDULE OR APPENDIX DOES NOT APPLY TO THE APPLICANT, WRITE "DOES NOT APPLY" IN RESPONSE TO THAT QlJESTION, SCHEDULE.OR-APPENDIX.
A L L P A G E S OF T H E FORM M U S T BE INITIALED BY THE, APPLICANT, IF ADDITIONAL PAGES ARE
REQUIRED IN-ORDER TO. ANSWER ANY QtJESTION, ADDITIONAL PAGES MAY BE UTILIZED AND MUST I BE ATTACHED TO THE FORM, BE SURE TO INDICA-TE THE NUMBER(S) OF THE.QUESTION(S)-BEING MiSWERED fiSa INITIAL EACH ADDITIONAL PAGE. SOME SCHEDULES MAY REQUIRE DISCLOSURE ; OF INFORMATION FOR MORE THAN. ONE NATURAL PERSON OR- ENTITY OR TYPE OF INFORMATION. ' IF THERE ARE MULTIPLE DISCLOSURES, MAKE ENOUGH ADDITIONAL COPIES OF THE BLANK SCHEDULE AND COMPLETE IT FOR EACH NAIURAL PERSON OR ENTITY OR TYPE OF INFORMATION,
PGCB-PE-1011 IV
c o p y FOR PUBLIC FILE
A L L REQUIRED DOCUMENTATION-SIJCHAS BUSINESS FORMATION PAPERS, TAX RETURNS AND APPENDICES. MUST BE SUBMITTED AT THE TIME OF FILING THIS FORM.
T H E APPLICATION FOR PENNSYLVANIA TAX CLEARANCE REVIEW MUSTBE SIGNED BY APPLICANT.
A L L AFRDAviTS, RELEASE AUTHORIZATIONS, AFFIRMATIONS. CERTIRCATIOI^S AND W A I V E R S O F
LIABILITY MUST BE SIGNED BY APPLICANT AND NOTARIZED. T H E LICENSEE'S AFFIRMATION MUST
BE SIGNED BY THE C E O OF THE BUSINESS ENTITY FOR WHICH APPLICANT IS A PRINCIPAL.
SHOULD YOU BE UNABLE TO UNIJERSTAND THIS FORM FULLY IN ENGLISH, IT IS YOUR
RESPONSIBILITY TO ACQUIRE ADEQUATE MEANS OF TRANSLATION, IF YOU SUBMIT A DOCUMENT
TO THE BOARD THAT IS IN A LANGUAGE OTHER'THAN ENGLISH, YOU,MUST ALSO SUBMIT AN
ENGLISH TRANSLATION COMPLIANT WITH, BOARD REGUUTIONS,
ALL NOTICES REGARDING YOUR APPLICATION WLL BE SENT TO THE ADDRESS YOU PROVIDE ON
THIS FORM. Y O U MUST IMMEDIATELY NOTIFY THE BOARD I F Y O U CHANGE YOUR ADDRESS,
FAILURE TO ANSWER ANY QUESTION COMPLETELY AND TRUTHFULLY WILL RESULT IN DENIAL OF
YOUR APPLICATION AND/OR REVOCATION .OF YOUR LICENSE, REGISTRATION, CERTIFICATE OR PERMIT AND MAY SUBJECT YOU TO CRIMINAL PENALTIES UNDER 18 PA. C.S, A. §4903, A N Y PERSON WHO APPLIES FOR AND OBTAINS A LICENSE, REGISTRATION, CERTIFICATE OR PERMIT FROM THE BOARD MAY BE REQUIRED TO SUBMIT TO WARRANTLESS SEARCHES WHEN PRESENT;IN A LICENSED GAMING FACILITY PURSUANT TO THE ACT-
CONFIDENTIAL INFORMATION (AS DEFINED IN 58 PA. CODE §401 A;3) SUPPLIED TO THE BOARD OR OTHERWISE OBTAINED SHALL NOT BE REVEALED EXCEPT IN THE COURSE OF THE NECESSARY ADMINISTRATION OF THE ACT, OR UPON THE LAV/FUL .ORDER- OF A COURT OF COMPETENT JURISDICTION OR, WITH THE APPROVAL OF THE ATTORNEY GENERAL, TO A DULY AUTHORIZED LAW ENFORCEMENT AGENCY. .AN APPLICANT OR LICENSE, REGISTRATION, CERTIRCATE OR PERMIT HOLDER WAIVES ANY LIABILITY OF'THE COMMONW'EALTH OF PENNSYLVANIA AND ITS INSTRUMENTALITIES AND AGEtJTS FOR ANY DAMAGES RESULTING FROM ANY DISCLOSURE OR PUBLICATION IN ANY MANNER, OTHER THAN A \M'LLFULLY UNLAVVFUL DISCLOSURE OR PUBLICATION,
PuRSiJANT TO BOARD REGULATIONS,.ONCE THE APPLICATION HAS BEEN FILED. APPLICANT MAY
NOT WITHDRAW ITS APPLICATION WITHOUT THE PERMISSION OF THE BOARD.
ALL REQUIRED DOCUMENTATION MUST BE SUBMITTED AT THE TIME OF FIUNG THIS FORM.
FURTHER, PURSUANT TO BOARD REGULATIONS, THE-APPLICANT IS UNDER,A CONTINUING DUTY TO
PROMPTLY NOTIFY THE BOARD IF THERE IS A CHANGE IN THE INFORMATION PROVIDED TO THE
BOARD.
A LICENSE, PERtvllT, CERTIFICATION OR REGISTRATION ISSUANCE, RENEWAL OR OTHER APPROVAL
ISSUED BY THE BOARD I S A REVOCABLE PRIVILEGE, t^o. PERSON HOLDING A LICENSE, PERMIT. CERTIFICATION OR REGISTRATION, RENEWAL, OR OTHER. APPROVAL IS DEEMED TO HAVE ANY PROPERTY RIGHTS RELATED To THE LICENSE, PERMIT, CERTIFICATION OR REGISTRATION,
B. PRINCIPAL ENTITY FORM
UNLESS OTHERWISE PROVIDED FOR IN THE GAMING ACT AND REGULATIONS, EACH PRINCIPAL; ' PERSON WITH CONTROLLING INTEREST, INSTITUTIONAL INVESTOR AND FINANCIAL BACKER THAT IS AN ENTlTY'MUST.COMPLETE,THE'PRiNCIPflL ENTITY FORM.
APPLICANTIS SUBMITTING THIS PRINCIPAL.ENTITY FORM BECAUSE IT IS A PRINCIPAL OF pA G_aming Ventures, LLC r \
PGCB^PE-1011 . V Initiars \ \ T
COPY FOR PUBLIC FILE
DESCRIBE THE RELATIONSHIP BETWEEN APPLICANT AND, BUSINESS ENTITY NAMED ABOVE, INCLUDING AMOUNTS AND TERMS OF OWNERSHIP AND CONTROL.
Joseph A. Domenico. as the sole member of J.D. Shore Financial LLC,' will be consultant to the Pennsylvania Casino Benefit Corporation ("PCBC"). PCBC will oversee and adrninister the distribulion of a portion of the net profits of the Category 2 flaming facilily proposed by PA Gaming Ventures, LLC ('PA Ventures') for charitable purposes.
IF YOU HAVE, ANY QUESTIONS REGARDING THE APPLICATION PACKAGE FORMS OR THE INFORMATION REQUIRED TO COMPLETE. ANY APPLICATION, PLEASE CONTACT THE PENNSYLVANIA GAMING CONTROL BOARD - THE BUREAU OF LICENSING AT (717) 346-3300.
PGCB-PE-'iOn VI initials
COPY FOR PUBLIC FILE
APPLICANT INFORMATION
' ' .•"•' '^5^^='i^•/ 'v:>^i'^"'•i^^;^'A;;?:^^
BUSINESS NAME AS IT APPEARS ON APPuCAMfs CERTIFICATE OF iNCORPOFWrioN, CHARTER, HYLAWS, PARTNERSHIP AGREEMEtrr OR
OThEROFFICIALOOCUMENTS(SPELLOUTCOMPLETH MAME, DO NOT USE AHEtREVlA"T10NS)
J.D. Shore Financial LLC
TRADE NAME(S) AND DOING BUSINESS As ("DBA") NAMES Does Not Apply Is THE APPUCANT A MINORITY OR WOMEN'S BliSINESS ENTERPRISE THAt !S CERTIFIED BY THE BUREAU OF Ml.-JORITY AND
WaMEN's BUSINESS ENTERPRISE OF .THE DEPARTMENT OF GENERAL SERVICES? L J YES ^ No
IF YES; PROVIDE CERTIFICATION UUMBER
•^^--^^V^iv^S^^^I-^-^ ' i 'V i ' i ' • ; . ; : ; t^--- ' •VV-AppUCANT^SPRiNClPAi>ADDRESS':^5>",^'''>-'''«;^ ' ^ :V '^^^^ NJV^-.'-^
AODRESS jJNE 1_
ADDR'GSS LINE 2
PERSONAL RESIDENCE
ADDRESS LINE 3
PHONE NUMBER PERSONAL PHONE FAX NUMBER ( )
^ : : - ^ y i } i ^ ^ - ^ - ' '•^•'.'•^••"'•--•'-AppLicANtlsADDRESS IN PENNSYLVA'NW^ .:••-.;-.•,•-
ADDRESS LINE,1 Does Nol Apply ADDRESS LINE 2
ADDRESS LINE 3
CITY STATE/PROVINCE POSTAL C O D E
COUNTRY EMAIL ADDRESS
COUNTY •TOWNSHIP WEB URL
PHONE NUMBER ( ) FAX NUMBER ( )
•"?> ^^^»^•••'^'^••:•^'^>•-iiV'-^l^'U: •^TCONTACTNAMEFORTHlS'AfJPU^iT lON' i^ '^ '^^K ' : : ' ' "^^
'•";|^^>^4^fA;v5:^'•>••^j.•i•;^V•>^^^;-'••:--^
,CHECK ONE
D SOLE PROPRIETORSHIP
a LIMITED LIABIUTY COMPANY
D OTHER (DESCRIBE)
a PARTNERSHIP D LI.MITED PARTNERSHIP
D S-CORPORATION n TRUST .
DC-CORPCRATION
PGCB-PE-IOII Initials'
c o p y FOR PUBLIC FILE
i i^^si iS^?^^5!s3;^i>pf^;?: i^^ ..-• ^ ^ - p ' j ! ' ^ ^ i A ^ ^ H i ^ H S S V ; : ; t ^ v ^ r
STATE OF INCORPORATION, REGISTRATION OR OTHER TYPE OF FORMATION
New Jersey DATE OF FORMATION
Apriri1,-201_2
APPLICANT'S BUSINESS JJAME AS IT APPEARS ON THE FORMATION DOCUMENTS
J.D. Shore Financial i L C
LIST ALL STATES IN VWICH THE APPLICANT IS CURRENTLY RECISTEReO OR AUTHORIZED TO DO BUSII ESS
'Nev/Jersey
is APRUCANT REGISTERED OR AUTHORIZED TO DO BUSINESS IN THE COMMONWEALTH OF PENNSYLVANIA? ' ^ Y E S ® NO
'!S>'''^^5iJ^^iCt'A-:>--/''^iJs^^i;-5;^ IDENTIFICATION NUMBERSV-^'HV>;-^^' ' ''S^^^^^^i^ \ ' l ^ ^ r ^ r ' FEDERAL EMPLOYER IDCNTIRCATION N U M B E R / T I N PAUNI ;MPLOYMENT COMPENSATION ACCOUNT NUMBER
PA DEPARTMENT OF REVENUE CORPORATE BOX NUMBER PA LIQUOR CONTROL BOARD LICENSE NUMBER
Does Not Apply
PA WORKERS COMPENSATION POLICY NUMBER PA DEPARTMENT OF STATE - ENTITY NUMBER
DqesNol Apply
D O E S THE APPLICANT HAVE ANYOUTSTA.'JPING TAX LIABILI HES TO HTHER THE COMMONWEALTH C * PENNSYLVyVtiAOR ANY
OTHER STATE QR THE FEDERAL GOVERNMENT?
IF YOU ANSWER YES, PROVIDE DETAILS CONCERNING ALL OUTSTANDING TAX LtA3ILmES.
-•;-^^^(t^3:^^^<^'>^^$^.\'^Ni•:^^^^^ ';;CRIMlNAL;HisfdRY • " '
T H E N E X T ' SECTION A S K S A B O U T ANY OFFENSES OR CHARGES APPLICANT OR ANY OF ITS OFFICERS,
DIRECTORS/PARTNERS OR TRUSTEES MAY HAVE COMMIXED OR HAD FILED AGAINST THEM, PRIOR TO ANSWERI 'NG THIS QUESTION, CAREFULLY REVIEW THE DEFINITIONS AND INSTRUCTIONS THATF.OLLOW.
DEFINITIONS FOR-PURPOSES OF THIS SECTION:
A. "CRIME' OR OFFENSE" INCLUDES ALL FELONIES ^ D MISDEMEANORS. AS WELL AS SUMMARY OFFENSES' THAT MAY HAVE REQUIRED YOL) TO APPEAR BEFORE A LAW ENFORCEMENT AGENCY, STATE OR' FEDERAL GRAND JURY, JUSTICE COURT. MUNICIPAL COURT, CITY COURT, TRAFFIC COURT, MIUTARY COURT OR ANY OTHER COURT EXCEPT JUVENILE COURT. INCLUDE ALL b U l / D W l OFFENSES.
B. "ARREST" INCLUDES ANY TIME THAT YOU WERE STOPPED 'BY A POLICE OFFICER OR-OTHER LAW ENFORCEMENT OFFICER AND ADVISED THAT YOU WERE UNDERARREST, DETAINED, HELD FOR QUESTIONING, REQUESTED BY A POLICE OFRCER ORLAW ENFORCEMENT OFFICER TO COME TO A POUCE STATION AND ANSV\CR QUESTIONS, TAKEN INTO. CUSTODY BY AfJY POLICE OFRCER OR OTHER LAW ENFORCEMENT OFFICER. FINGERPRINTED. HE'LD IN JAJL, OR, INSTRUCTED TO APPEAR IN COURT OR, SUBPOENAED TO ANSWER FOR CONDUCT 'Mi\CH IS A CRIME AS' HAS BEEN DEFINED IN PARAGRAPH "A,"
C. "CHARGE" INCLUDES ANY INDICTMENT, COMPIAINT. INFORMATION, SUMMONS, .CITATION OR OTHER NOTICE OF THE ALLEGED COMMISSION OF ANY CRIME OR OFFENSE AS DEFINED IN PARAGRAPH "A."
INSTRUCTIONS 1. ANSWER "YES" AND PROVIDE ALL INFORMATION TO THE BEST OF YOUR ABILITY EVEN'IF;
A'. Y o u Dip NOT COMMIT THE OFFENSE CHARGED;
B. T H E . ARREST OR CHARGES W€RE DISMISSED OR THE CHARGES WERE SUBSEQUENTLY DOWNGRADED TO A LESSER CHARGE;
C. Y o u PLEADED NOT GUILTY OR NOLO CONTENDERE;
PGCB-PE-1011
c o p y FOR PUBLIC FILE
D. . YOU COMPLETED AN ACCELERATED REHABILITATIVE DISPOSITION ("ARD") OR EQUIVALENT DIVERSIONARY PROGRAM;
E. T H E CHARGES OR CONViCTIOl^ WERE EXPUNGED FROM YOUR RECORD, EVEN IF
YOU HAVE EXPUNGEMENT PAPERS;
F. YOU WERE NOT CONVICTED OR WERE FOUND "NOT GUILTY";
G. YOU DID NOT SERVE ANY TIME IN PRISON OR JAIL;
H. T H E ARRESTS,,CHARGES OR OFFENSES HAPPENED AuONG-TlME AGO;
I, YOU WERE ARRESTED OR CHARGED IN ANOTHER STATE (A STATE OTHER THAN PENNSYLVANIA);
J . YOU WERE,NEVER.PHYSICALLY TAKEN INTO CUSTODY A N D / O R TRANSPORTED TO A POLICE STATION OR JAIL.
2. A N S W E R " N O " IF;
A. Y o u HAVE NEVER BEEN ARRESTED OR CHARGED WITH ANY CRIME OR OFFENSE;
B. YOUR ARREST HAPPENED WHEN YOU WERE UNDER I 8 YEARS OF AGE AND YOUR COURT APPEARANCE WAS IN JUVENILE COURT.
F A l L u R E TO F U L L Y A N S W E R THIS QUESTION M A Y R E S U L T IN THE DENIAL OF YOUR A P P L I C A T I O N .
1 . H A S I A P P L I C A N T O R A N Y O F ITS OFFICERS, DIRECTORS/PARTNERS OR TRUSTEES EVER
BEEN INDICTED, CHARGED WITH OR CONVICTED OF A CRIMINAL OFFENSE-OR BEEN A PARTY
TO ,dR NAMED AS AN UNINDICTED CO-CONSPIRATOR IN ANY CRIMINAL PROCEEDINGIN THE
C O M M O N - A / E A L T H OR ANY OTHER JURISDICTION?
I F Y O U ANSWER Y E S , YOU MUST COMPLETE SCHEDULE 6 CONCERNING CRIMINAL
HISTORY,
DYES a NO
^:a•^i:^jg;||jt^i^^^:^^:}9^v:^^?^^
2. H A S A P P U C A N T O R A N Y O F ITS O F R C E R S , D I R E C T O R S / P A R T N E R S O R T R U S T E E S EVER
BEEN CALLED TO TESTIFY BEFORE, BEEN THE,SUBJECT OF AN INVESTIGATION CONDUCTED BY; OR REQUESTED TO TAKE A POLYGRAPH EXAM BY ANY GOVERNMENTAL AGENCY, COURT, COMMITTEE, GRAND JtJRY-OR INVESTIGATORY BODY (MUNICIPAL, STATE, COUNTY, PROVINCIAL, FEDERAL, NATIONAL, ETC,) OTHER THAN IN RESPONSE" TO MINOR TRAFFIC RELATED OFFENSES?
I F Y O U A N S V / E R Y E S , Y O U M U S T C O M P L E T E S C H E D U L H 7 CONCERNING TESTIMONY.
INVESTIGATIONS OR POLYGRAPHS,
>-^>AHTITRUSTi^TRADE,REGUl!AtlON&'SECURrriES0UPGMENTS;STATl^^^^
3, H A S APPLICANT. OR ANY OF ITS AFFILIATES, INTERMEDIARIES, SUBSIDIARIES OR HOLDING COMPANIES EVER HAD A JUDGMENT, ORDER, CONSENT DECREE OR CONSENT ORDEFt PERTAINING TO A VIOLATION OR ALLEGED VIOLATION OF THE FEDERAL ANTITRUST, TRADE REGULATION OR SECURITIES LAWS. OR SIMILAR LAWS OF ANY STATE, PRQVINCE-OR COUNTRY ENTERED AGAINST IT?
D Y E S S N O
4, I N T H E ' PAST TEN (10) YEARS. HAS APPLICANT, OR' ANY OF ITS AFFILIATES,
INTERMEDIARIES, SUBSIDIARIES OR HOLDING. COMPANIES HAD A JUDGMENT, OF{DER/ CONSENT DECREE OR CONSENT ORDER-PERTAINING TO ANY STATE OR FEDERAL STATUTE; REGULATION OR CODE THAT RESULTED IN A FINE OR PENALTY OF $50 ,000 OR MORE ENTERED AGAINST IT?
IF YOU ANSWER Y E S TO EITHER QUESTION, YOU MUST COMPLETE SCHEDULE 9 CONCERNING A N T I T R U S T , T R A D E R E G U L A T I O N S S E C U R I T Y J U D G M E N T S ; S T A - R J T O R Y A N D
REGULATORY VIOLATIONS,
DYES a NO
PGC8-PE-1011 Initials '•
c o p y FOR PUBLIC FILE
r* " •^'•-''•^^;^^^-i^f:^v?v":Sji^^:^^ 5. H A S APPLICANT, OR ANY OF ITS' AFFILIATES. INTERMEDIARIES, SUBSIDIARIES' OR HOLDING COMPANIES HAD ANY PETITION UNDER ANY PROVISION OF THE FEDERAL BANKRUPTCY C O D E OR UNDER ANY STATE. iNSctvENCY LAW'FILED BY OR AGAINST IT IN THE LAST TEN (10) YEAR PERIOD?
D YES 1^ NO
6, HAS APPLICANT. OR ANY OF ITS AFFILIATES, INTERMEDIARIES, SUBSIDIARIES OR HOLDING COMPANIES SOUGHT RELIEF UNDER ANY PROVISION OF THE FEDERAL BANKRUPTCY CODE OR UNDER. ANY^STATE INSOLVENCY" LAW IN THE LAST TEN (10) YEAR PERIOD?
D YES 0 NO
7, HAS A COURT APPOINTED ANY RECEIVER, FISCAL AGENT, TRUSTEE, REORGANIZATION TRUSTEE, OR SIMILAR OFFICER FOR APPLICANT,' OR ' ANY OF ITS AFRLIATES, INTERMEDIARIES, SUBSIDIARIES OR HOLDING COMPANIES IN THE LAST TEN (1OJ YEARS?
IF YOU ANSVVER YES TO ANY OF THESE QUESTIONS, YOU MUST COMPLETE SCHEDULE 10 CONCERNING BANKRUPTCY OR INSOLVENCY PROCEEDINGS.
n YES m NO
.V'^•VL•^^J^^^*^A='v:'^'^'^^V.:^Ti^?S^'APPU^
8. HAS APPLICANT. OR ANY OF ITS AFFILIATES, INTERMEDIARIES,, SUBSIDIARIES OR HOLDING-COMPANIES APPLIED FOR. ANY LICENSE'OR'PERMIT BY A, GOVERNMENT AGENCY FOR tHE CO-LECTlON OF SALES AND USE TAX, SELLING AN'D SERVING LIQUOR AND'fMLT BEVERAGES, PROVIDING OVERNIGHT LODGING SERVICES OR ANY OTHER ACTIVITY REQUIRING A LICENSE OR PERMIT? AiGOVERNMENT AGE_NCY ASUSED HERE.INCLUDES ANY SUBORDINATE CREATURE OF'FEDERAL, STATE. NATIVE AMERICAN OR LOCAL GOVERNMENT CREATED t o CARRY OUT A GOVERNMENTAL.-FUNCTION,.OR TO IMPLEMENT.A STATUTE OR STATUTES.
IF YOU ANSWER YES, YOU MUST COMPLETE SCHEDULE-11 CONCERNING NpN-GAf/iNG LICENSES AND PERMITS.
• YES E)NO
9. HAS APPLICANT, OR ANY OF ITS AFFILIATES; INTERMEDIARIES, SUBSIDIARIES OR HOLDING COMPANIES APPLIED FOR ANY LICENSE OR PERMIT BY A GOVERNMENT AGENCY-CHARGED vyiTH REGULATING GAMES OF CHANCE, INCLUDING*BUT NOT LIMITED TO SLOT MACHINES, VIDEO LOTTERY TERMINALS, TABLE :GAMES, HORSE RACING, JAI 'ALAI, ETC,?' A GOVERNMENT AGENCY AS USED HERE, INCLUDES Af Y' SUBORDINATE- CREATURE OF FEDERAL, STATE. NATIVE AMERICAN OR LOCAL GOVERNMENT CREATED TO CARRY OUT A GOVERNMENTAL FUNCTION OR TO IMPLEMENT A STATUTE OR STATUTES:
IF YOU ANSWER YES, YOU 'MUST COMPLETE SCHEDULE 12 CONCERNING GAMING LICENSES ANDPERM.ITS.
.D YES S NO
• •r" i>vKn^? '- l= '-'K^-i-^ ' ^^ApPLlCANT:s CONTm^ DlSBUfiSEMENtS^^ :l=v?fjVs^'^>V^"-^'>^i' ^
10, DURING THE LAST TEN (10)'YEAR PERIOD, HAS-APPLICANT,, ITS PARENT COMPANY, OR ANY OF ITS AFFILIATES, INTERMEDIARIES, SUBSIDIARIES, HOLDING COMPANIES. DIRECTORS, OFFICERS, EMPLOYEES OR ANY THIRD.PARTIES ACTING FOR OR-ON BEHALF OF APPI,1CANT MADE ANY BRIBES OR KICKBACKS OR MADE'ANY PAYMENTS ALLEGED TO HAVE' f3EEN BRIBES OR WlC;<BACKS TO ANY EMPLOYEE, PERSON. COMPANY OR ORGANIZATION TO OBTAIN FAVORABLE TREATMENT?.
11. DURING THE LAST TEN.(10) YEAR,PERIOD, HAS APPLIC-ANT, I I S PARENT COMPANY, OR ANY OF ITS AFFILIATES, INTERMEDIARIES, SUBSIDIARIES, HOLDING,COMPANIES; DIRECTORS, OFFICERS. EMPLOYEES OR ANY THIRO' PARTIES ACTING FOR OR ON BEHALF OF THE APPLICANT MADE ANY BRIBES OR KICKBACKS OR MApE-Atrr' PAYMENTS ALLEGED TO HAVE BEEN BRIBES OR KICKBACKS TO ANY GOVERNMENT OFFICIAL, DOMESTIC OR FOREIGN TO OBTAIN FAVORABLE TREATMENT?
12. DURING THE LAST TEN (10) YEAR PERIOD, HAS'APPLICANT, ITS PARENT COMPANY, OR ANY OF ITS AFRLIATES, INTERMEDIARIES, SUBSIDIARIES', HOLDING COMPANIES,-DIRECTORS. OFFICERS, EMPLOYEES OR ANY THIRD PARTIES'-ACT ING FOR.OR ON BEHALF OF APPLICANT LOANED FUNDS FOR THE PURPOSE OF OPPOSING OR SUPPORTING ANY GOVERNMENT. POLITICAL PARTY, CANDIDATE OR COMMTnEE, EITHER DOMESTIC OR FOREIGN?
PGC3-PE-1011
COPY FOR PUBLIC FILE
13. DURING THE LAST TEN (10) YEAR PERIOD,,HAS APPLICANT, ITS PARENT COMPANY, OR ANY OF ITS AFFILIATES, INTERMEDIARIES,'SUBSIDIARIES. HOLDING COMPANIES, DIRECTORS. OFFICERS, EMPLOYEES OR ANY THIRD PARTIES ACTING.FOR OR'ON BEHALF OF APPLICANT DONATED OR LOANED PROPERTY OR ANY OTHERTHING OF VALUE FOR-'-FHE PURPOSE OF OPPOSING OR SUPPORTING ANY GOVERNMENT, POLITICAL PARTY, CANDIDATE OR COMMITTEE, EITHER DOMESTIC OR FOREIGN?
14,, DURING THE LAST TEN.(10) YEAR.PERIOD, HAS'APPLICANT, ITS PARENT COMPANY, OR ANY OF ITS AFFILIATES, INTERMEDIARIES, SUBSIDIARIES OR HOLDING COMPANIES MADE ANY LOANS, D0^JAT10NS OR OTHER DISBURSEMENTS TO DIRECTORS, OFFICERS, EMPLOYEES OR ANY THIRD PARTIES FOR THE PURPOSE OF REIMBURSING SUCTt INDIVIDUALS FOR POLITICAL CONTRIBUTIONS EITHER FOREIGN OR,DOMESTIC?
15. DURING THE LAST TEN (10) YEAR PERIOD, HAS APPLICANT, ITS,PARENT COMPANY, OR ANY OF ITS AFFILIATES, INTERMEDIARIES, SUBSIDIARIES OR HOLDING COMPANIES MAINTAINED ANY. ,BANK ACCOUNT. DOMESTIC OR FOREIGN, NOT REFLECTED ON THE APPUCANT'S:BOOKS OR RECORDS?
16. DURING THE LAST TEN (10) :YEAR PERIOD, HAS APPLICANT, ITS PARENT COMPANY, OR ANY OF ITS AFFIUATES. INTERMEDIARIES. SUBSIDIARIES ,0R. HOLDING COMPANIES
MAINTAINED ANY NUMBERED ACCOUNT OR ANY ACCOUNT IN THE NAME OF A NOMINEE FOR APPLICANT?
IF YOU ANSWER YES TO ANY OF THESE QUESTIONS, YOU MUST COMPLETE SCHEDULE 13 CONCERNING CONTRIBUTIONS AND DISBURSEMENTS. ^
PGCB-PE-lOn
COPY FOR PUBLIC FILE
APPLICATION CHECKLIST
PLJACE A CHECKMARK IN EACH BOX NEXT TO EACH,ITEM APPUCANT HAS ATTACHED TO THIS PRINCIPAL ENTITY FORM,
.EACH ITEM MARKED AS MANDATORY MUST BE COMPLETED ANDSUQMITTED AS PART OF THIS APPLICATION FORM. IF ANY ITEM IS MISSING. THE APPLICATION 'AflLL BE CONSIDERED INCOMPLETE AND WILL NOT BE PROCESSED.
m
S
E
El
m
s
0
s
El
El
El
El
E!
E!
El
'E)
^
•a
a •
El
E)
E!
SCHEDULE.1 ;.OTHER NAMES USED BY APPLICANT
SCHEDULE 2: ADPRESSES USED BY APPLICANT
SCHEDULES: CURRENT OFFICERS. DIRECTORS/PARTNERS AND TRUSTS
SCHEDULE 4; APPLICANT'S OWNERS
SCHEDULE 5; HISTORY OF INSURANCE CLAIMS
SCHEDULES; CRIMINAL HISTORY
SCHEDULE 7: TESTIMONY. INVESTIGATIONS OR POLYGRAPHS i
SCHEDULE 8: EXISTING LITIGATION
SCHEDULE ,9: ANTITRUST, TRADE REGULATION AND SECURITY JUDGMENTS;
STATUTORY AND REGULATORY VIOLATIONS
SCHEDULE 10; BANKRUPTCY OR INSOLVENCY PROCEE_DINGS
SCHEDULE 11: NON-GAMING UCENSES AND PERMITS
SCHEDULE I 2:.GAMING LICENSES AND PERMITS
SCHEDULE 13: AppLiCANrs CONTRIBUTIONS AND DISBURSEMENTS
SCHEDULE,14: APPLICANT BACKGROUND PART I
SCHEDULE 15: APPLICANT BACKGROUND PART 2
APPLICATION FOR PENNSYLVANIA TAX CLEARANCE REVIEW
. AFFIDAVIT
RELEASE AUTHORIZATION
WAIVER OF LIABILITY
LJCENSEE'S AFFIRMATION
PENNSYLVANIA POLITICAL CONTRIBUTIONS FORM
FINANCIAL STATEMENT CERTIFICATION
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
,MANDATORY
MANDATORY
MANDATORY
PGCB-PE-lOr, 6 Initials
c o p y FOR PUBLIC FILE
APPENDICES: THE APPENDICES ARE DOCUMENTS THE APPLICANT MUST PROVIDE OR CREATE. THE APPENDICES
ARE NOT REPRESENTED IN THE APPLICATION QUESTIONS OR ITS SCHEDULES. EACH APPENDIX SHALL BE
PRESENTED IN A TABBED MANNER AND EACH TAB MUST INDICATE THE APPENDIX NUMBER AS LISTED BELOW. IF
AN APPENDIX DOES NOT APPLY TO AN APPLICANT, WRITE " DOES NOT APPLY" ON THE APPENDIX PAGE,
^
E]
S
iSI
E)
El
m .
m
E)
El
E)
El
E!
E]
El
APPENDIX 1; EXISTING LITIGATION
APPENDIX 2; AUDITED RNANCIAL STATEMENT FOR THE LAST FISCAL.YEAR. IF THE
APPLICANT DOES NOT NORMALLY HAVE ITS FINANCIAL' STATEMENTS AUDITED, ATTACH UNAUDITED FINANCIAL STATEMENTS.
APPENDIX 3: AUDITED FINANCIAL STATEMENTS FORTHE LAST FIVE (5), YEARS. IF THE
APPLICANT DOES NOT NORMALLY HAVE ITS FINANCIAL STATEMENTS AUDITED, ATTACH
UNAUDITED FINANCIAL STATEMENTS.
APPENDIX 4; ANNUAL REPORTS FOR THE LAST FIVE (5) YEARS.. ^
APPENDIX 5: ANNUAL REPORTS PREPARED ON THE SEC's I O K F O R THE LAST FIVE
(5) YEARS.
APPENDIX 6: A COPY OF THE LAST QUARTERLY UNAUDITED.FINANCIAL STATEMENT.
APPENDIX 7; A COPY OR COPIES OF ANY INTERIM REPORTS.
APPENOIX'8: A COPY OF THE LAST DEFINITIVE PROXY OR INFORMATION STATEMENT
(SEC).
APPENDIX 9: A COPY OF ALL REGISTRATION STATEMENTS FOR THE LAST FIVE (5)
YEARS FILED IN ACCORDANCE WITH THE SEliuRITlES ACTOF 'l 933.
APPENDIX 1 p: COPIES OF ALL OTHER REPOJ^TS PREPARED IN THE LAST FIVE (5)
YEARS BY INDEPENDENT AUDITORS OF THE APPLICANT:
APPENDIX 11: CERTIFIEIJ COPIES OF THE ARTICLES OF INCORPORATION, CHARTER.
BYLAWS. PARTNERSHIP AGREEMENT OR OTHER OFRciAL DocuMENTSANO ALL AMENDMENTS AND PROPOSED AMENDMENTS,
APPENDIX 12: CURRENT OWNERSHIP TABLE OF ORGANIZATION.
APPENDIX 13: COPIESOFT120 'FORMS, 94TFORMS ANDALL.OTHERBUSINESS
RELATED TAX FORMS FILED WITH THE I R S IN THE LAST FIVE (5 ) YEARS.
APPENDIX 14: COPIES OF 5500 FORMS FILED VVITH THE iRS INTHE LASTFIVE (5)
YEARS.
APPENDIX.1 5: DESCRIBE CRIMINAL HISTORY OF^APPLICANT. THISlNFORfAATION MUST BE PROVIDED IN ADDITION TO THE INFORMATION PROVIDED IN SCHEDULE 6. NARRATIVE INFORIMTION ABOUT THE NATURE OF CHARGE OR COMPLAINT AND THE
DISPOSITION MUST BE PROVIDED.
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
-
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
MANDATORY
PGCB-PE-1011 I.iitiaW'
in
c •z.
a m
7: S
X n X >
•a
•u
r- 0 >
Z - ? M
0 0 •z
m
03
c 3 rn
0}
tn
>
z D
0 ^ •*
^
• T
)
in
0 X 1 H
m
zi
tr,
X
3J
Cfl
0 I m
c 1- m
_k 0 H
I m
:n
Z >
m
UI C
C/l m
0 GO
•<
>
D
.TJ r 0 >
2:
o ,0 c Cl
I 2 >
le
oo
i
•• o n "O
cn
a vo 3. 3' s ••--
^
o o c 3 -<
m 5 F >
a c •n
m
m
w
'-
"D
1 O
z.
m
2 s
^ ? 1 -
J
&
a SJ
in
01 Ifl
rr
O :3 > 1 z o m
•D
o f o o a m
£ a x m
tn
In
r- z m ' > o D3
m
(n
r- ni
ro
g e X CD
•0
c :u
1)
O
CD
fn
'
> a u :3] ra
Ul
Ul c Cl
tn
Tl
71 o .5 > o o 31
tn
W
Ul
C
m
O
,- H ,'
£. f t y ' ;-"
-'t -"-•
X
v' >.
^v
, '"*
^'•i
. "' ";•:
•
'•'•
'. '-.'
)'
."
i. '.s
-• y S\ %
/-••
-r '. y I
o o e z H ;• <
rn 1 >
o o :a
in
cn
(fl
—
13
T
• o H
c tn
3
1
•"
• -n
-'£
s: i
g o 3J
tn
cn
tn r z m
Cl O ; Ol
•D
:<]
O < 5 n m -u
o O
o fn
&
o 3J
m
tn
M
z tn m
cn
tn
r^
• z to
s • V S
(n
T! s u O m 5 • tn
(n c (n in s & o 3)
m c cn m
O
••• >>.
•:;
• \ :', 1;.
*; •; ' •s 1 %
•-. i l:i .;:
V. 1' ' ..
"i 7- 1 '•'I'
i
.•
=,
^•V
i •
(• -'; ^ ^^ i 1 9 ':, >»
;-. •^ t'- 1 i
1%: t 1 1 s ±
c z -J -<
m
§ F >
• • :•
m
in
in
—
ti
X o Z
c: to
m >
m
3)
•&
D
?
: m
(t
l 0
1 r- z m
u n tn
3 •0
o S
•z.
o m
-0
O
tn %
O
O
tn
&
• 3)
tn
M
z m o 01
01
rr Z
m
to
'&^?
• •
. 7
1 ••
'
«:.
T
J o tn
m a m
.m
cn
tz
cn tn
O
T-.
O s tr,
tn
C
VI
m
H
O
1
_'l
?;
1-;
:'( ..-;
V V , .
-*
•
ij,' ^.
A;
•'rt $ li?-.- "5- 1 ••j'i •
,'
'^ •'i"
"j*^
;*i'
lif.
• \
•v
.'t
.i; ''
£. .'is 1 t § ' •'i. >
'i i 1 !-i
i'?
• 1 • • ^H
^
^H
^
^H
1 •u m
w
O z > r ni
S >
r
^K
^^
H
^^
H • ^
H 1 1 •0
m
CO
O
—a
- r X o z m o g z :o
-<
m 5 F >
13
a X
m
in
in
' .
•
-0
n:
O S
z c £ a IT >
z n 31
g • 33
m 1
• ^^1 I • • • •
If tn
• -1
3
• o O
a in
&^
£ D
^
H
O
£H
^
tn
^H
tn
O
l ^
B
in
cn ^
H
VI
r- z m . > o S!
tn
t^
Z
in
IO
(A o z >
r >
' o a
30
m
>
S
-1
cn
C 71 o s
CD
•
1/1'
»
—.
tn
=i
cn
c in
m
13
H
O i 'i
i \ J' 1 •
^ 1 L^'
'o 1 '(*; 'V.
;i 'i: jV
:£
.'1
1 "
-_T
. •
i'~
'J 'ft- •
' ;i;
it .'v j- .. 'i -' 1.1'
4
-^'
•'
:;
J";; 4- 4
: 14
2 13
So
5 n
I X
n n
n: >
f/>
i/
i w S
c m
u
0 tj <
? X
X —
« t/
5 0 ()
z -1 n Z
D
s- r tn
01
n T
III
0 C
T-- m
K) >
1 1
tJ
m
cn
C
Ul >
X
•a
L >
Z
c o H
X m
311=
1 o
na
nd
do
j A
do
o
>
z o =1
•I >
o a =d
o z ri::^
>
3 5 W
o M
-0
t/>
(D
3 (0
3 cr ra
1^1
K
fttf
1 1 _ 1 i ^^ !•
Ki
K i 1 j K
^
-n
3) o >
-1
m
-1
o >
H o T)
O
tn
-1
O
z >
z z c >
o o m z o 2 ? C
•"
n tn
g
CD
O
O
tn
Z
H
s§
I o
fn
S
—
m
z tn
o z •0
m
n :?
> 1
- ^c
n n O
3 S
(o
tn
o z CO
.'
^•
-
."1"
•'
\
't \. i'.
't '\ '§'.
6 5 ffi;
r m
>
z O
7) .Tl'
O
Ifi
:d
o Z'
i m.
rr. o
p"
^ -1
>.
z Q
-1
x:
6"
c 33.
m
z TJ o CA
3 o z >
z o 71
2 z Cl
>
n P >
o CA
•;V
l
;.
'-
•
.'i'
'•'x
•^ -% - .'
"-- i.'i
M^ 9:1
'
^^^^
i
3^
K
i^
K
S
B
^
1 ^
E D ^
B
S
IBI
^ ^
H
cn
B
••O
'
m i 1
?
t '•
1 m
TJ
»
'Z o z m
31
m
en
tn
r- •z m
(
J
H'
B 1 ^
^ !'
ll
Mi
n •U
rn
He
n o o m
p ii 11
'—
1 ^
H
rPi I"" 3 BI 9 MH •0
m
70
tf
i o z >
r > D
m
tf)
tf) m
(T
. <n
f- M
•
CO
G
O
-1
ra
z >
5^
^ 0)
o
. 9J
. r f o 3
^ (9
3
-1
IU
O
-0
o cn
.3
o z
s "1
i':^
1^,
""* 1 i'C
^•
^-
ij _ ;-:
;? 1 i •;
>_•,
ll *:'
'A
'IJ v.- :|
'?•'.
j^
l ^
v v^; 1 1- 1 •? 1 ':,-
. ^ 1- ' t v" I % 1 1 1 ("•
- •1
'
•i- r- 1- -;. i
|s 11
lifl
•
ram
B
.€
K
'*"
E
g E
O
p
n E
t?
B
1 • 1 1 jB i -0
g 2 2 i
^ z c a:
m
31
3>
D
O
3J
m
cn
r- iZ
m
CJ i' H 1 •H
i
H
•1
Si
81""
m
w g m
m
11
W
r~
I ^
9 m
1 "
1 • i K0H >
• o :J
J m
tn
c
n z m
ro
o w
•a
3-
——
>
o iO
3 -n 8"
R M 1 g •S
» C m 1
tn
-i Z >
s m
o rt
z (tl
-1 z
•>
K
n
.^
tl
3<
c/>
p O 5 m
o n j;
H X 5
^ -'I' i;
-(••
• '- r-s -i"
.Ji
7* i
'Y:
<"*
•i
r'-'
\'C
;i
i.t.
^ jfti
i-if; z >
s m
>'
•
Z' o 5:
m
O'
X m
CA
tf
i'
tu !? 1 J_
"
5K f i-iS Sl
3i; ii I •
i'i
'^i^
>? 'i ''<
ir
-'ti
'A
J .1
:
Si
m
H
z 3:
c o >i
5 1
Li
z >
O
I-
73
C
S
z
>
O
z!
S§
^ O
tn
;o
-D
O
m
-n
P
O
m
:u
tn
o '73 m
n -1.
o 7}
tn >
-i
Z
m
73
O
z H
o 75
cn
O
75
tD
m
Z m
-3
n >
m
in
O
Tl >
.-t 73
C
03
n X m
c c r-- m 6 c T
J 7)
m
z -I
O
-n
-n
o m
73
73
m
o -H o,
73-
tfi >
-I
z m
7}
CA
>
z o H
.73
CA
^7/z
/ on
an
d uo
d A
doo
"T
V
••
^• Vy
'-<
.~-_
J' s.
».-..-
"i-";
;• D
m
w
o » 5 fn
2 > H
C
7)
m
~ ,' -<
TJ m
m.
7)
S' (/>
>
z o b o z o H o z CO
b TT
O
z m
^ '" ':'
'''
• f
i i* 'f --.'
-'i
' 't
'^
^i
'".V
Be Hi 1 IM
^
M
^a
l ^J
H
EB
g ^^
9 '
^a
g
Hi
^S^H
^
BS
9 ^
«l
^H
H
5 ..-
z £ tu
n 7)
T)
7:
o m
z S
cn
I TJ
BD i i
B
'^
K
^ En
'^
R
tt
K
.
§ D
33
cn
tn
tn
'?
Ill
tJ
^^ 1
1 • • • 1 mm
^
Wv'
o
lm
P
^^
m If 8 a m
il il [9^
^^
|rT
^
'
&
c 31
n tn
tn
r- z rr.
ro
c-
-n
s ^
(/I
W
CD
-t
m
——
—
>3 o z 5
.Of
QJ
Z
—-
n
rn
o
• ,
tn
Tl 5<
"C
33
"(0
m
p • 5 tn
O
•n ^
i :.
-•
v:-.
'--J
1 •v
'. «
- >.
:. k ^ 1 •J? •. • 1 ^- •J.
'•'^i
.
•, .••' i ? ,^
:v
z ,D.
m
(A
CA
',
•_•
-Tr.
'•^
•''
'•:•
••-
tC'r'
i-'''
K'-; P
,"
.-v^
^^
'•;.
•;
- I '-j'' a >.-.--
.-.- i-""
' 1 \)' ' ''•" *'*
'''- .'-
• • •
ii
TJ
" C
A
^
R
>
o
S
Z 7
)
E]
r-
-
3S <
^
O
tn
o X
rn
a a.
t- m >
-x
-o
r o >
z H
CA
6 z m
H7/
-/ o
na
nd
do
d A
do
o
to
},t
-.\i .•:! \v
:K"
33
m
H
CA
C
o
> 2
cn
'"
- J
^ >
is o
o o <
z m
•n
n OJ
-1
X m
r ^
CJ
Tl
•>
l~
r- z CA
c >
? ()
tn
n !..
<
tn
rn
o a c m
cn
T
H O
7)
-<
O
o <
X
T"
m
O
o
z CA
c ? z rj
m
O
H7/
i/ o
na
nd
do
d A
do
o
-3
o o CD
•13 o L>J 5 1^-
£-i
i>
P<5.
'"^^
""'-"'
v^
{ ^
i-- '
^v
\
o o m
cn
o >
-0
•0
T-
•<
-
•
o ,z
o
>
o s
^ m
^
?
33
C^ z >
H
C
Is
1 5
z ?
-<
7) o m
o » o o
>
33
M
•n
O
£ J
Z
33
-(
o m
>
o o c -1
o '<^
^
o ^
01
^ Q
g
m
o P
2
a cn
S
tn
w
m
- P
o >
7
?•
O
!-
>
m
5
S
=-
z S
•"
?
5 51
g
p 0
^ 5
<
;o
0 >
m
(-
1 3J
0
2 m
73
^
S.
m
2 m
tn
-1
z
.w
H
CA
m
z -( m z 0 m
0
0 R
=
a
CJ
m
-•
0 0
3J
33
-n
s ?
^ s
s s
"'
"*
K
Z
fl
in
33
3)
-
-.
-.
•,
Jj.?
;' •'
i;^
'^ I
^
!•
'.^
••
-•
-.
.;
V-
" •
••
^ ; •
', .'
•'
.•
'-
.
; -.*:
; -
> -
V'!
A-
-•;
• ••
.-,_
'••
:•.
•-;
;.
-;
.•
.
CiV
.:
-.••;-
-; f' ^e
i-'
'^
•^
^
<^;
,?".
^'•
.^
'.:
z iiy
J^
i^i-
r~i-'
-'*5'
lL
-;T
(A -
f.
o-'"
»;
.' iV
Z''
, O
''"
• ;t
rr
ii.
Z'"
""
-i:
:"
I »<
t:
-,'-
;'..-
L-:
- ^y
i^t»
•'-
•'
;.'
i.
.7-^
: •
r-\
^T
.v;-.--
i •
Vf:
'
5 :-.
'i^
'T^ r
•^
,;
•
' ••
;.. .
V.
"'
: ,•
•
•5-
="•
t?-*"
t'l
• .:
J •••
•
--..
!-;
•.
'"
ll'--
,' i.
r. >
^ > -
fA ^ ,11
m
u <
m
m
0 n c rrt
-(
•
0 ^ _>
0 z >
0 m
w
-11 II
f) <
n 11! 1 m
0 h ^ z 'O
/• -n >
t3 /-
tn
r>
.1: rn
11
c m
<n
0 TT ^ -t
0 T)
-<
H7/
i/ o
na
nd
do
d A
do
o
e
z £ c 31 n o •n
33
O
O m
m
o z a (n
O
3J z <
m
in § -(
O z g o 2 >
3 n H fn
o •n
-n
O n _3J
-o
fn
o z tn
33 o 73
—1
3) c -1
m
lit
2 s 5 in
p
Z >
III >
z o &
o 33
m
cn
cn
O
•n
O
O
,3a -i
O
3) 3 1 m
B >
O
in
2 o -<
° 1
" i;t
in
D
d
g i -<
o <
m
z -0 -I
m
o z s I n I H
tn
(n
d ?• b z <
? >
(A
o <
2 >
<
5 m
S
W
33
-t
o D
i<
5 1
g 3 H £ tn
•D
,m
.»
5 o o •n
/• '(''
'•
r
' -\
m
tfi
H s o z _-<
z <
tn
CA
S >
H
O
Z 6 7] O -<
CD
73 >
-0
X
m^ z o o m
z -1
• ^
•.
"' *_'
z 5 c 3) m
o •n
TJ
31 o o m s 2 O
tn
O
3
1 3 m
irt o >,
~i o z i u >
•:
m
H
I n:
O n m
33
o 33 m
o -1
o tl
2 111
3:
o X
73 c tr.
IT!
nx
2 <
O <
rr.
p
.
Z
tn
z o >
a 3)
IT. cn
o •n
O
o 31
-1
.Q
33
O
-1
I m
31 >
CD
ni
Z o <
-<
>
(n
§'
1 -c
O
in
•o O
-1
o z S
I o I H
in
tn
H e o z -<
s tn
•ff
l 1
z >
m
"0
in
3
3 -4
O
o
><
. if
°
^ -<
s in
TJ
in
70 O o o -n
' ,
[ t.
'•','
-i
m
tfi
=J
5 O
z z <
m
CA
>
H o z o 7)
ro
o r- ^ 71 >
•0 z _ z n 5 m
z -1 ^ .'- ,'*.
, '
. '
i
"-',
*C- - :'
z >
C
31
fn
o Tt
"O
st o n m
m
O
z CD
c
n
O
3} 5 ni in
-1
O >
6 z >
z o 2 >
S
m
-1
X
tn
o -n
-n
n m
33
o 5 fn
o o 3) >
33
z m
31
O
31
-H
73
C
In
-1
fn
m
2 s s p
BE
9 z
Dn
£ l^
^^
l m
' ^3
^ ^I
^H
PH
>
B
H^
I O
l^
iH
,^
^SsV
'^
^
^ ^ T
l O
o 3)
H o 31 >
m
z n -<
a d
§ i -<
CT
Z
-
3 a >
-I
in
O
z 5 I n X -1
m
in
H s O
2 -<
? S
O z
15
m"°
tn
ro
-H
O
O
>
i
OS
-t
? m
T)
tn
33
O o o •n
, j - !'
•.-'
J-
'•
'
'..--- -^7 t.
1 -'•:
-"--.
I .'.
'.-'. ;.'
•-
'.' * -*'",
; 1
J ^ m Cfl,
H
i o z ,-<
z <
m,
CA
H
C
l >
H 6 z o"
Tl.
"D
O -<
Cl ?;
.Tl
I ^
z o (3
m
z H *. "; ^ --, 'i. •^
s
'*'
_'
n >
z -1 >
2 CO
3) m
D -<
m
to
-1 o D
c tii
CA
-
4 o 2 ro
o 2 m
CJ
TJ
73 ? H
X m
Tl o f- O 5 z o z •n
O
71
-1 O
Z
O
X
m
D
c (—
•m
-s|
-1
m
(A
s o z z <
-1
.
o >
-I
• o z CA
o 73 TJ
O
r- -<
Cl ? TJ X
C
A
3ii
d o
na
nd
do
d A
doo
2 >
3J
in
o -n
I IT.
o >
cn
.
Z
.tn o -n
>
i~
Tl >
-I
m
cn
_i
o c o >
5 o z
2 >
m
o o tn
m >
z o o o o ;<
fn
~4
z c ,^
m
73
rr
O
n >
-1
'o
2 Z
m
o •n 8 c 3
J H
DJ
ft]
tl o 33
m
n I c -1 ? o z pi
-•0 fTl
z o z CT
I m X z o C
H
O
>
H O
z ,,- .'. ' ' /l'
z >
-1
c 33
m
O
"n H
I fn
o ^ 0
)
Z
m
tn
o •n >
m
<n
-<
O
-CT
>
H o z
• o m
l;l z o >
T3
TJ.
f- <
Z >
m
o -n
o £ fn >
z o D
o n :s 3 2 c 0
3 17
1 X
1" o o >
O
z c z >
s m
O
•n g C
33
H
CJ
fn
•n
O
73
fn
• I
n X
r;
-I 6 >
s 2 in
•3
m
2 'O
2 o
-.;
, * * .•- tn
X
CO
-i z O
E:
H ci
>
-t
o z t ••
''
2 C
fl d
o
>
m
2 O
^is
rri
f=<
:>5
"o,c
S
o -J
^
m
o
il
o6 3^
_ O
O
>
O
So
g m
Q
-
= s
9
_,
TJ
^ "
" "
^ I
-
m
m
L_
-f.
-<
-f
5 "1
n
2 r-
y
• <
>
8i
- o
m
X
-r
m
ip
si
" o
•^
2
O ?
5 ^3
>
o m
C
l z
si
rn
3/
Z
-I
zl
Cfl >
m
O
m
o (-
•"
3}
>
2
O
-f,
£ >
T
l >
5
c 3"
—
m
> e
^
F;
S
(-
_(
^'-n
i D
' o
o -*
o 2 b m
C
A
OS
°1
3
-o o
o c =3
O
> °
TJ
• o
^? >
a
z o
-I
o o -
q
X
.-(
X
D
O
tn
<
O
O
C
>
5
(D
o n
m 5
=
Cfl
m
S
^ ^
2 2
2-
2 m
S
X
H
o o
X
2
o >
m
T
] W
"O
2 -!
O
77
.
7)
to
TD
o 5
2 £
H
-<
O
X
m
O
c r m
00
m
X
CA
d z Cl (-
>
o
H7/
z/ o
na
nd
dOd
Ad
oo
'
>
c iri
o Tl a tn
'r' o m
O
3J
m
tn
o SJ
O
33
m
3J
5i.
1)
o c/l
-1
o z a o c 3'
rn
o D
o;
o tn
o D
O
tn
cn in
O a o m
31
2 .5
C
31
m
o Tl o -n
•n
, rn
2 M
m
2 >
•fn o n 5 tr.
O
O
O
m
-1
Z c •
s •1
m
73
'O
H
m
o Tl c o m
Z -( O g .m
3
1
O
31
D
m
n 31
m
m
Z
in >
z • >
a o XJ
m
tn
cn
O
Ti >
o tn 2 n -<
o 3J n o c 3J
H 1 I- <
m
O
< '
j* ^ <
O
r- >
-i O
z ,. '-.',
'X".'
•^
i' ; i : -,
1.'
2 g S
O
-n
C
tn
.§
O 0 o 73
tn
r.i
O
73
O
D
tn -a
o M
O z D >
o c :]
fnr
C3 D
n o 5 o -fn o D
O
tn'
(A
.cn o D
-1
J!
m
31
•
2 5 c 31
fn
o •n
O
Tl
n z tn
m
*
O
o m
cn
Z o >
TI
TJ
r- -<
2 >
tri • 11 O £ m
o o fn
H
•z c 3 31 O 5 IT
. o Tl
c D
Cl
Z -1
o 31
D
m
71
O
3J
..•
m
o 31
m
m Z >
rr. >
z o >
C3
O
3:
fn
tn
cn
o •n >
Cl
tn
Z
o -t o 3J o o c 3 o I- <.
m
D
k- .t
••
^ 1 '..
•.-
•;
,
"•
''
.
-j- j ;-;
.•i.
'(-•
•;,
v-
• ,'
•
'•
-.
' '.-- t. V- •3 %
>•"
• )•
<
."
•.
r^-
if \- .^
o t~"^
^ -(
•» o z.
:V-
• •:
.•,
•V
-
d •
.^
^
•i:
V
.
1=
i L' --.-.
'..
;•••
-
1
r 1 _ '
1-,
p^
• ^ ^ i.v
••
•
'^i > r !
3) -<
III
rn
-1 n o (_
-<
o in
CO
O
o z V (.>
CJ -n
31
U <
r:i
T rn
Tl
U
i~
o o 2 o 71 ^ o z
M
O
X c:
fT-
m
CO
>
j:
H
H
71
C
CJ
H H
•>
O :•
m c>
t~ t -1
o BO
(fl
m
o r- J) :
•m
z Cfl
-i >
-i r -t n 71
K >
r C3 7}
rn
O
c t H O
71
•<
<
O
t>
-H o v;
CA
H7/
^ o
na
nd
dO
dA
do
o
I I
>
•
2 > -(
c 31
m
CJ
t_
c £ m
z -1 o 3
J 7)
P
m
•n
•
a >
-1
m (_
c o O
Z ^ o 3
3 m
c m
-n m
z -*
m
31
fn
a
^ 2
m
a tn
T
l O
o >
TJ
o :Z
• tn
o 7
3 tn
O
tn
<
m
33 s m
Z
-J
o :B o i m
7]
m
O
tn <
tn
33
> Cl
m 3 o 3)
-4
33
C
CA
-1
tn
m > o z -H
tn
D
a o tn-
cn.
Z o -f >
TJ
TJ
f- -< C
fl o c o 'I H
z o Tl rs
> tn
Oo o o n !l!
z a 73
O >
H m
TJ
(n
H
-I O z Tl
1-
tn
o O
33
73
fn
m
•n
Z >
>
z o >
o o 3J ITI
IA
CO
o I m
Z n •<
o 3J
O
O
c 33 1 g 5 m
O
;.. \ •" - ~
It '•. t. ; .*
--.'
s.
'.:
':\
:ii^
CD
>• z 73
C
Tl
•^ <- O
z CA
.
<
Z-.
o,
-<
•
TJ
71.
C
n m
m
o Z'
Cl
CA
V-.
.>
v.^
,-
i; •f n >
-
t >
f >
m
JJ
rn
u -<
ni
Cfl
o n I m
H
O :• CA
(11 >
Z »)
73
O
2 ' .;)
71
n <
1- rii
Tl o o ^ r,i
w
n X m
o m
-A
ro
t- z 7..
73
1 -
TJ
H o -<
o 2 tl <
m
n -<
Tl
71
(1
r>
m
m
D
.7- (.)
Ul
Bii
d o
na
nd
dO
dA
do
o
QD
aa
an
'DD
7)
S
O
tf
l m
z?
* /-
\ r-
rn
^ O
c
z cn
;5
§
I S
-m
73
d
2 o
>
O
a S
Z
m
, 2
m
O
rn
T]
o C
l X
fn
m
31
2
z >
£
-• "
>
5
5 g
° s
D •
D a
o a.
D D
D Q
D n
na
n n
o C
fl m
TJ
o
Gl
O
,(=
X,
ni
tn
73
2 cn
3
2 z
J.
5
o y
ff
tn
:n
d 2
D
>
O
D
5 z
m
z m
O
7)
H
m
in
z o
o ,c
fl m
T3
. o
Cl
O
c X
m
, m
'3
3 2
CA
3
2 Z
>
C3
;S
31
S
m
Z
nn
DD
n'a
aa
TJ
SO
Wm
TJ
OO
X
m
m
3J
12
Z
2
>
TJ
.9
m
z
.S
O
p
tn
rn
rr.
O
rn
a:
3J
p m
? 6
Cl
S '
"
5 m
in
tJ
3
5 §
s p
< .
o g
S cn
S
." o >
r -I
>
i" >
III
31
m
o <
III <fl ^ u n f i;
i
H
O z 03 n z r,i
III *.
n <
n rn
Tl
f~
o _ o < >
o 2 n in
rn
o T tn
O
L
» _
k
•:£ o r n ? Cl
f- (1
z >
2 D
"U
^ -H
H7/
J 0/
7e/7
c/ ^
OJ
Ac/
00
na
aD
DD
.DD
S' I i
-2
O
J!
o
o
tfl
m
T3
o
o
c X
m
IT
. 3
1
cn
2
z
2
>
:D
S
ri
z
m
z
CJ d
D D
D D
D D
• •
!•'• •
• n
.n •
dn
nn
Da
aD
D
XS
OC
fl
tn
TJ
OO
m
^
-f-t
r-
-X
fn
m
-r.
m
3-
o
c
X
<
d
z
(A
-
tu
£
O
D
S
2
m
2 tn
D
O
O
Cl
tn
m 3
1
--
z
>
t"
5
o
d
p
s
X.
5: O
cn
m T
]! o
o
m
=-
oc
Xm
m-
" <
d
z
c
"tJ
^ ^
g D
2 S
m
'?
d
, z
o
>
O
o
S Z
{n
z
m
o
™
2
fn
z
m
z
• H
Tl
^O
Cn
rn
Ti
aO
r
n^
OC
Xi
nm
aj
£d
zW
2Z
z>
o
>
z
7)
S
fn .
2
m
z
• d
00
s
3!
C
Cl
f
z
z
tn O
2
2
5 o
is
'-'
-r
'—
z ^
=J
m
a
fn
o >
p
O
fn X
5> tn
-o
2
5
31
3J
-I
o
m
^
£ z
g
n 2 o
^' 'la t~
l z ->
(t
II
I 11
73
u H •I
in
11 n r- n >
•7
0 n 31
•t.
-1
(J
'Z
Tl
CJ
-u
H
X
tn s.
H
n .d
-^
0 <
Tl
m
71 n u
tn
a f n m
_L ro
0 S
7- Cl r- 0 <A >
^ D Tl
Tl <
H
CA
H7/
z/ o
na
nd
dOd
AdO
O
T3 o n tu T3
m
J o
* to
o -io
—jr
^"
^^
^^
4^^
^ ^'
^ -
fl
•"•
'
v
•
^-"v
. ^,
^
— .
z >
-1
c 73
m
O
Tl o o z H
71
m
c H
O
z CA
o 71 a 0}
03
c 3!
CA
m
5.
m
z H CA
o o c z --I
31
-<
m
£ r- •g
-o
33
m
tn
cn
—
Tl
X
o _
z m
Z
c 5 CD
m
31
—
Tl
- Z
c H
I
31
>
O
71
tn
tn
cn
[7
2 tn
CO
n
....
_ CA
> -1
TJ
3J
o z TJ
O
cn
-1 > n o o m
^ a 3J
tn
CO
tn
i—
2 m >
o D
31
tn
cn
l~
2 m
ro
Tl
3J
cn ^ Z > m
S
• m
Z >
tn
Cfl
c •n
Tl
tfi ? b n v
.>
—
; -' . 4 '. •z. >- m
>
z D >
ni
tn
CA '' '" . ', :.
n o cr
z -1
31
-<
m
^ f— g o TJ
m
CO
cn
-, .
-t X o
_ z m 2 c S
CD
m
3J
-^
Tl
—
z c ca
m
3J
>
tD
Jl
m
in
cn |- 2 m
to
ifl
-1 > 1 o < o m
T3
O
cn
-1 > n o o rn
&
CJ
3?
m
%
r- S
3J
in
cn
cn
2 fn
to
Tt
31
cn -( Z > ft
i ^ s r-,f
n 2 > •: 2 > s m
tfi
c Tl
Tl
73
tfi
X
fr
-1
p -^ *~
» '•^ '•>
F. • .'|.
I- •-.
I 'I •j- z >
^ >
z • >
D
a;
71
^ Ci>
'- K "." '_J
'i* *"
;• I. '3.
•L]
1,
•.
*.
'
O
o c 2 -( 3J -<
m
£ >
o 33
tn
en
cn
•r-
Tl
X o
-^
2 tn
2 c £ tn
33
—
Tl
- 2 3 n 33
>
• 7>
tn
cn
cn r 2 in
CJ O
-1
tn
-I
CJ
TJ
O < tn
TJ
O
cn > n o C3
in
-c 3 CJ
•^
IH
^ ^S
—4
H>
IB
si
-i
jH
1 r|
H
>
t3
33
rn
cn
cn
2 m
fo 1 ^ 6 i- 17
1 Z
>
s cn
-1 >
m
Cfl
Tl
Tl
X
'C
73
tfi
31 a p
•^
TT
^
"i"* 'i:
• '
:
!•
/i,"
• •• -,' >
•:?
••X--
. r
:.l 1, : : -, ^;
•^ S 2 >
^: i 7
1 m
CA
CA
••i
'i\ ,-*
'• -•:,
^ :;-,
, -
-•
i' '; '\- • -
.'•-'.
• •
# . .
- >
•_
;•
• ';
••
•
•.
--
;.
--.•
•
i-:.
S o
to g
73
rn
cn X
m
S
o
§S
o o
C'T
J 5
tfl
Z
" G
l O
^
-n
X
I!
5 T
J tfl
CA
-( r
r,
25
n'
>
TJ
m
o • 7
] O
>
TJ TJ n >
z -t >
z Cfl m
7)
m o -<
m
Cfl.
>
m
O
X
H
r m
—1
O
tfl
Cfl
X
•>
2 O
O
l A
TJ
2
71
P:i
m
Cl
D
rn
2 -
r"
X
§'i
7)
S
O
2 2
Tl
O
O
X
m
o
> m
5 o
71
71
o o 71
5 tfi > z o
Bii
d o
nan
d dO
dAdo
o
?
<
\'0 z n 71
. O
O
c o .-
I Cfl -b
-71
•O
o c o m
D
>i'
z G
•o
Tl
Cfl
tn i o m
(A
>J m
•z o tn
71
m
D
••;f)
o tn
CA
n Tl
d o 'Z' o Tl o o •3'
.TI
m
;H
id <
tn
O
o z a o z cn
T3
O
01
Cl
TJ O
CD
o 03
a QJ"
o o 5
o 3 P.
CO
o s Tl b CO
o o a cr
^ :
Cl ^ c CD
3 Ol O
-1
03
O
=i'
f )
U
o
;o
m
tfl
n 2 T3
O;
TJ
,7)
(A
--H
cn
tfl
n X
tn
O
c at
c CA
z Dl >
o 7; o Tl
O
c z o T) >
73
3ii
d o
na
nd
dOd
Ad
oo
KJ
NJ
O
m
tn
n ;2
;-o
•d o . z
o Tl w
'C
CA
.Z
tn
• O
m
• <
tn, r- ••
O
m
• z
'Z n :CT
.->
,z ;
:7]
:c
•TJ -I n ij
<
.7) tn
o rn
•<
m
73
cn
X
Tl o 71
W
'.S
-T)
•,3 O
O fS
g z Cl
(fl
o X m
o c •3
CA
z m
CD
>
O
CJ
71
O c z ,o
T3 J>
71
-i
^7/z
/ 0/
7e/7
c/ ^
Oi/
AdO
O
c o p y FOR PUBLIC FILE
PENNSYLVANIA POLITICAL CONTRIBUTIONS FORM
I N T H E CHART BELOW, PROVIDE THE REQUIRED INFORMATION FOR ALL.POLJTICAL CONTRIBUTIONS. MONET ARYOR IN-KIND, TO A CANDIDATE FOR, NOMINATION OR ELECTION TO ANY PUBLIC OFFICEIN THISOOMMONWEALTH, OR TO ANY POLITICAL COMMITTEE OR STATE PARTY IN THIS COMMONWEALTH OR TO ANY GROUP, COMMITTEE OR ASSOCIAI'ION ORGANIZED IN.SUPPORT OF ANY SUCH CANDIDATE, POLITICAL COMMITTEE OR.STATE PARTY- ON OR AFTER THE DATE YOUR ENTITY'S APPLICATION WAS SUBMITTEDTO THE PENNSYLVANIA GAMING CONTROL BOARD (BOARD). T H E APPLICANT OR LICENSEE MUST LIST POLITICAL CONTRIBUTIONS BY I T S .AFFILIATES, INTERMEDIARIES, SUBSIDIARIES, HOLDING COMPANIES, PRINCIPALS AND KEY EMPLOYEES^ VVHO HOLD ,SIMILAR GAMWG LICENSES IN OTHER JURISDICTIONS. DO NOT INCLUDE CONTRIBUTIONS TO CANDIDATES FOR FEDERAL OFFICES OR TO'COMMITTEES OR GROUPS ORGANIZED SOLELYJN SUPPORT OF FEDERAL CANDIDATES.
IF THERE IS MORE THAN ONE CONTRIBUTION TO THE SAME CANDIDATE, POLITICAL COMMITTEE; STATE PARTY. ETC., SEPARATE ENTRIES MUST.BE LISTED FOR EACH CONTRIBUTION..
N O T E ; I F YOU NEED SPACE FOR ADDITIONAL ENTRIES, PLEASE MAKE ADDITIONAL COPIES OF THIS'FORM.
DATE OF
CONTRIBUTION
z'
NAME AND ADDRESS OF THE CANDIDATE, POLITTCAL COMMITTEE OR STATE PAR'n', OR GROUP, COMMITTEE OR ASSOCIATION
ORGANIZED IN SUPPORT OF SUCH CANDIDATE, POLITICAL COMMITTEE OR STATE PARTY
DOES NOT APPLY
1
• ^ \
AMOUNT OR VALUE OF
CONTRIBUTION
-
EO/AuTHORiZED SIGNATORY ATE SIGNED
Joseph A. Domenico
PRINTED NAME OF CEO/AUTHORIZED SIGNATORY -T iTLE-
PGC8-PE-10:i
APPENDIX 1: EXISTING LITIGATION
c o p y FOR PUBLIC FIL
APPENDIX 2: AUDITED FINANCIAL STATEMENT FOR THE LAST FISCAL YEAR. IF THE APPLICANT DOES NOT NORMALLY HAVE ITS FINANCIAL STATEMENTS AUDITED, ATTACH UNAUDITED FINANCIAL STATEMENTS.
APPENDIX 3: AUDITED FINANCIAL STATEMENTS FOR THE LAST FIVE (5) YEARS. IFTHE APPLICANT DOES NOT NORMALLY HAVE ITS_ FINANCIAL STATEMENTS AUDITED, ATTACH UNAUDITED FINANCIAL STATEMENTS.
APPENDIX 4: ANNUAL REPORTS FOR THE LAST FIVE (5) YEARS.
copy FOR PUBLIC FILE
APPENDIX 5: ANNUAL REPORTS PREPARED ON THE SEC'S 10K FOR THE LAST FIVE (5) YEARS.
Does Not Apply. J.D. Shore Financial LLC is a privately held limited.liability company that was formed on April 11, 20'12.
COPY FOR PUBLIC FIL
APPENDIX 6; A COPY OF THE LAST QUARTERLY UNAUDITED FINANCIAL STATEMENT.
COPY FOR PUBLIC FIL
APPENDIX 7: A COPY OR COPIES OF ANY INTERIM REPORTS.
copy FOR PUBLIC FILE
APPENDIX 8; A COPY OF THE UKST DEFINITIVE PROXY OR INFORMATION STATEMENT (SEC).
Does Not Apply. J.D. Shore Financial LLC Is a privately held limited liability company that was formed on April 11, 2012.
c o p y FOR PUBLIC FILE
APPENDIX 9: A COPY OF ALL REGISTRATION STATEMENTS TOR THE LAST FIVE (5) YEARS FILED IN ACCORDANCE WITH THE SECURITIES ACT OF 1933,
Does Not Apply. J.D. Shore Financial LLC is a privately held limited liability company that was formed on April 11, 2012.
APPENDIX i 0: COPIES OF ALL OTHER REPORTS PREPARED IN THE LAST FIVE (5) YEARS BY INDEPENDENT AUDITORS OF THE APPLICANT.
COPY FOR PUBLIC FILE
APPENDIX 11; CERTIFIED COPIES OFTHE ARTICLES OF INCORPORATION, CHARTER, BYLAWS, PARTNERSHIP AGREEMENT OR OTHER OFFICIAL DOCUMENTS AND ALL AMENDMENTS AND PROPOSED AMENDMENTS.
See Attached.
COPY FOR PUBLIC FILE
CERTIFICATE OF FORMATION
OF
J.D. .Shore Financial LLC
flOSiASUH This Certificate of Formatitbn dated April .11, 2012 is
being duly executed and filed by R. W. Worthington, as an
authorized person, to form a limited liability company under the
New Jersey Limited Liability Company Act. /^tjOO 3 <P <5"^ \0
1. The name of the limited liability company is
J.D. Shore Financial LLC
2. The name and address of the limited liability company's
initial registered office and agent is:
John Donnelly, Esquire 3030 Atlantic Avenue Atlantic City, NJ 08401
3. The duration of the limited liability company's existence
shall be perpetual.
The undersigned represents that this Limited Liability Company
has one or more members, and that this filing complies, with the
reciuirements detailed in NJSA 42:2B. The undersigned hereby attests
that he is authorized to sign this certificate on behalf of the
Limited Liability Company.
Dated: April 11, 2012
1R. W. Worthington, Authorized person
APPENDIX 12; CURRENT OWNERSHIP TABLE OF ORGANIZATION.
COPY FOR PUBLIC FILE
APPENDIX 13: COPIES OF 1120 FORMS, 941 FORMS AND ALL OTHER BUSINESS
RELATED TAX FORMS FILED WITH THE IRS IN THE LAST FIVE (5) YEARS.
APPENDIX 14: COPIES OF 5500 FORMS FILED WITH THE IRS IN THE LAST FIVE (5) YEARS.
COPY FOR PUBLIC FILE
APPENDIX 15: DESCRIBE CRIMINAL HISTORY OF APPLICANT, THIS INFORMATION MUST BE PROVIDED IN ADDITION TO
THE INFORMATION PROVIDED IN,SCHEDULE 6. NARRATIVE INFORMATION ABOUT THE NATURE OF CHARGE OR • COMPLAINT AND THE DISPOSITION MUST BE PROVIDED.
Does Not Apply.
