N.J. Admin. Code § 13:69A-5.4 - Personal History Disclosure Resubmission Form

(a) A Personal History Disclosure Resubmission Form shall be the PHD-1 and may require the applicant to provide the following information:

1. Name;

2. Date of birth;

3. Physical description;

4. Current address;

5. Social Security number, or the reason why the applicant does not have that number, which information shall be utilized solely for tax administration as provided under 42 U.S.C. § 405(c)(2)(C)(i) and N.J.S.A. 54:50-25 and for child support enforcement as provided under 42 U.S.C. § 666(a)(13) and N.J.S.A. 2A:17-56.60;

6. Citizenship and, if applicable, resident alien status, including any employment authorization and expiration date since the date of the submission of the applicant's initial license application or last Resubmission Form;

7. Telephone number at current place of employment;

8. Employment history since the date of the submission of the applicant's initial license application or last Resubmission Form;

9. Any denial, suspension, revocation or disciplinary action of a casino gaming industry license, permit or certification since the submission of the applicant's initial license application or last Resubmission Form;

10. Civil and criminal proceedings in any jurisdiction since the submission of the applicant's initial license application or last Resubmission Form, as follows:

i. Arrests, charges or offenses committed by the applicant;

ii. Lawsuits to which the applicant was or is a party; and

iii. Any financial liens or judgments filed against the applicant in this State or in any other jurisdiction; and

11. All assets liabilities of the applicant, applicant's spouse and dependent children, as indicated on the net worth statement and supporting schedules in a format prescribed by the Division, including the following:

i. Bank accounts, including any right of ownership in, control over or interest in any foreign bank account as well as with regard to safe deposit boxes;

ii. Loans and notes and other receivables;

iii. Securities;

iv. Real estate interests held by the applicant or the applicant's spouse or dependent children;

v. Life insurance;

vi. Pension funds;

vii. Loans, notes and other payables;

viii. Taxes payable; and

ix. Mortgages or liens on real estate.

(b) In addition to the information in (a) above, a completed Personal History Disclosure Resubmission Form shall include the following:

1. Copies of Federal and New Jersey tax returns and related information;

2. A signed, dated and notarized certification of truth; and

3. A signed, dated and notarized Release Authorization which shall direct all courts, probation departments, selective service boards, employers, educational institutions, banks, financial and other institutions and all governmental agencies, Federal, state, and local without exception both foreign and domestic, to release any and all information pertaining to the applicant as requested by the Division.

Notes

N.J. Admin. Code § 13:69A-5.4

Amended by 50 N.J.R. 601(b), effective 1/16/2018