NATIONAL INDIAN GAMING COMMISSION

90 K Street NE, Suite 200

Washington, DC 20002

TEL:202-632-7003

FAX: 202-632-7066

MANAGEMENT CONTRACT BACKGROUNDINVESTIGATIONS

Subject: Instructions for the submission of required information including Standard Form 85P 

and Supplemental Information

Pursuant to National Indian Gaming Commission (NIGC) regulations, 25 CFR Section 537 -

BACKGROUND INVESTIGATIONS FOR PERSONS OR ENTITIES WITH A

FINANCIAL INTEREST IN, OR HAVING MANAGEMENT RESPONSIBILITY FOR, A

MANAGEMENT CONTRACT, the NIGC Chairman shall make a determination of suitability

for a person with a financial interest in or having management responsibility for a management

contract based upon a background investigation conducted for that purpose. In order to

efficiently conduct an individual background investigation, it has been determined that the

following documentation shall be submitted to the NIGC:

Standard Form 85P-Questionnaire For Public Trust Positions

Supplemental Information Pu rsuant To 25 CFR Section 537.1(b)(l)

Privacy Notice and Notice Regarding False Statements (2)

NIGC Authorization for Release of Information (2)

Fair Credit Reporting Act Release (2)

Fingerprints (2 Original Cards)

Form 8821 -Tax Information Release (2) (Will be provided at

commencement of Financial Background Investigation)

All questions and requested information shall be answered accurately and completely. If no 

response is necessary or applicable, please indicate by entering "None" or "NIA". Submit two (2) 

copies of each document -photocopies are acceptable as long as all pages contain original 

signatures and dates in black ink. (Fingerprint cards must be originals and completed cards must

be received from an appropriate federal, state or tribal law enforcement agency. See §

537.1(b)(3).

In completing Standard Form 85P (SF 85P), please pay careful attention to the section

"Instructions for Completing this Form" on the cover sheet. Some questions on the SF 85P 

specify a time frame of seven years, which is not consistent with 25 CFR Section 537.1 (b)( 1).

Therefore, in order to meet the standards of 25 CFR Section 537, the following questions should 

be answered for the timeframe indicated:
9.Residences: Provide ten (10) years of the information requested in this section. In

addition, please provide the city, state and country of residence from age eighteen

(18)to the present on the Supplemental Information form, Section (iii.)

11.Employment: Provide information for the past ten (10) years.

20. Police Record: In completing this section, please be sure to provide the following

information pursuant to 25 CFR Section 537. l (b)( I ):

(ix) For each gaming offense and for each felony for which there is an

ongoing prosecution or a conviction, the name and address of the court 

involved, the charge, and the dates of the prosecution and the disposition;

(Information for this section should be provided regardless of when the

offense occurred.)

(x) For each misdemeanor conviction or ongoing misdemeanor

prosecution (excluding minor traffic violations) within ten (10) years of

the date of the application, the name and address for the court involved, 

and the dates of the prosecution and the disposition;

(xii) For each criminal charge, (exclud ing minor traffic charges) regardless

of whether or not it resulted in a conviction, ifsuch criminal charge is

within ten (10) years of the date of the application and is not otherwise 

listed pursuant to paragraphs (b)(l)(ix) or (b)( l )(x) of this section, the

name and address of the court involved, the criminal charge, and the dates

of the charge and disposition; ...]

Itis not necessary to complete the "Authorization for Release of Medical Information." 

However, please be sure to complete the "Authorization for Release of Information".

In addition, please assure that a $10,000 investigative fee deposit has been submitted to the

NIGC for each individual for whom a background investigation will be conducted. . A 

background investigation cannot be commenced until this deposit has been received.

Careful attention to the accurate and complete submission of all requested information and

documentation will greatly expedite the background investigation process.

If there are any questions, please contact Background Investigations Manager, Jon Duran at (702) 

592-5789.
NATIONAL INDIAN GAMING COMMISSION

90 K Street NE, Suite 200

Washington, DC 20002

TEL: 202-632-7003

FA){: 202-632-7066

MANAGEMENT CONTRACT BACKGROUND INVESTIGATIONS

Subject: Supplemental Information Pursuant To 25 CFR Section 537.1(b)(l )

In addition to the completed Standard Form 85P, the following information must be provided to

the National Indian Gaming Commission pursuant to 25 CFR Section 537.l (b)(l) [Information 

may be provided on this sheet or in another format that provides the same information. If

additional space is required, please attach additional sheets as needed. Each additional sheet

must contain the individual's name, date of completion and be initialed by the individual.]:

(ii) A current photograph (taken within 90 days of the date of this submission),(:) 

Driver's License Number,(:)

and,

A list of all languages spoken or written;(:)

(iii) ...the city, state and country of residence from age eighteen (1 8) to the present.(:)

Applicant's Name: Initials: 

Contractor/Tribe : Date: 
(vi) A description of any existing and previous business relationships with Indian tribes,

including ownership interests in those businesses;(:)

(vii) A description of any existing and previous business relationships with the gaming industry 

generally, including ownership interests in those businesses;(:)

(viii) The name and address of any licensing or regulatory agency with which the person has filed

an application for a license or permit relating to gaming, whether or not such 

license or permit was granted;(:)

(xi) A complete financial statement showing all sources of income for the previous 

three (3) years, and assets, liabilities, and net worth as of the date of 

submission;(:)

Applicant's Name: Initials: 

Contractor/Tribe: Date: 
25 CFR Section 537.l(b)(4) PRIVACY NOTICE

Solicitation of the information in this section is authorized by 25 U.S.C. 2701, et.seq.

The purpose of the requested information is to determine the suitability of individuals with a 

financial interest in, or having management responsibility for, a management contract.

The information will be used by the National Indian Gaming Commission members and

staff and Indian tribal officials who have need for the information in the performance of

their official duties. The information may be disclosed to appropriate federal, tribal, state 

or foreign law enforcement and regulatory agencies in connection with a background 

investigation or when relevant to civil, criminal or reg ulatory investigations or

prosecutions or investigat ions of activities while associated with a gaming operation. Failure

to consent

to the disclosures indicated in this statement will mean that the Chairman of the National

Indian Gaming Commission will be unable to approve the contract in which the person has

a financial interest or management responsibility.

The disclosure of a person's Social Security Number (SSN) is voluntary. However,

failure to supply a SSN may result in errors in processing the information provided.

25CFR Section 537.l(b)(4) NOTICE REGARDING FALSE STATEMENTS

A false statement knowingly and willfully provided in any of the information pursuant 

to this section may be grounds for not approving the contract in which I have a financial

interest or management responsibility, or for disapproving or voiding such contract after it is

approved by the Chairman of the National Indian Gaming Commission. Also, I may be

punished by fine or imprisonment (U.S. Code, title 18, section 1001).

Executed at , 

On this day of , 20 . 

Signature 

Subscribed and sworn to before me on this day of

 , 20 . 

NOTARY PUBLIC

Applicant's Name: Initials: 

Contractor/Tribe: Date: