This attestation form, the United States Citizenship Attestation Form, is Part 1A of the Nebraska Lottery Retailer Application, which the Nebraska Department of Revenue (DOR) publishes on its website. Sole proprietorships use it to attest that they are a citizen of the United States or a qualified alien under the federal Immigration and Nationality Act. On FillingPDF you can fill out the form online and download or print the completed PDF; the form and the full application are published by the DOR, and the completed application goes to the Nebraska Lottery by fax or mail.
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What is Part 1A?
The United States Citizenship Attestation Form is the Nebraska form on which an applicant states, for the purpose of complying with Neb. Rev. Stat. §§ 4-108 through 4-114, that they are a U.S. citizen or a qualified alien under the federal Immigration and Nationality Act.
The form offers two alternative statements. In the first, you attest that you are a citizen of the United States. In the second, you attest that you are a qualified alien, write your immigration status and alien number, and agree to provide a copy of your USCIS documentation upon request. A closing paragraph has you attest that your response, and the information on the form and on any related application for public benefits, is true, complete and accurate. It also states that the information may be used to verify your lawful presence in the United States.
The Nebraska Department of Revenue (DOR) lists the form as Part 1A: Attestation Form of the Nebraska Lottery Retailer Application, alongside Part 1 (Application Form - Main), Part 2 (Background Information), Part 3 (Financial Information) and Part 4 (W-9 Taxpayer Identification). It is one part of that larger application, not a stand-alone application. The revision printed on the form is 7/2009, and the form prints no form number of its own; "Part 1A" is the label the DOR page uses. The generic title "Attestation Form" refers here only to this Nebraska citizenship attestation.
Who needs to file Part 1A?
Sole proprietorships applying for a Nebraska Lottery retailer contract complete this form. The DOR's lottery retailer application page states that only sole proprietorships need to complete Part 1A, so applicants organized in another way are not asked to complete it.
Within the form, the person making the attestation chooses one of two statements:
- You are a citizen of the United States.
- You are a qualified alien under the federal Immigration and Nationality Act. You then give your immigration status and alien number and agree to provide a copy of your USCIS documentation upon request.
The form prints one name line and one signature line and says nothing about signing for someone else, so the person making the attestation prints their own name and signs. The other parts of the retailer application (Parts 1, 2, 3 and 4) have their own requirements; see the application instructions listed on the DOR page.
When to file Part 1A
Part 1A is completed with the rest of the Nebraska Lottery Retailer Application, so it goes in whenever you submit that application. The form prints no due date of its own. Date it on the day you sign it: the DATE line sits under the signature line. If you attest as a qualified alien, be ready to provide a copy of your USCIS documentation when it is requested; the form sets no time limit for that request.
Documents you need
- A copy of your USCIS documentation, only if you attest that you are a qualified alien and the agency requests it; the form does not ask you to attach it.
How to fill out Part 1A
Confirm that Part 1A applies to you
The DOR page says only sole proprietorships need to complete this part of the Nebraska Lottery Retailer Application. If your business is organized another way, you are not asked to complete it.
Read the purpose statement
The form opens by saying it is completed for the purpose of complying with Neb. Rev. Stat. §§ 4-108 through 4-114, and then asks you to attest as follows.
Mark the citizen statement if it applies
Choose "I am a citizen of the United States" if that is true. Do not also complete the qualified alien statement, since the form separates the two with "OR".
Complete the qualified alien statement instead
If you are a qualified alien under the federal Immigration and Nationality Act, write your immigration status and alien number on the line provided. This statement also commits you to provide a copy of your USCIS documentation upon request.
Read the truthfulness attestation
By signing, you attest that your response, the information on the form and any related application for public benefits are true, complete and accurate. The form also states the information may be used to verify your lawful presence in the United States.
Print your full name
Under PRINT NAME, enter your name in the order the form shows: first, middle, last.
Sign the form
Sign on the SIGNATURE line. The form has one signature line and no section for a representative.
Date the form
Enter the date you sign on the DATE line.
Review and download the completed PDF
Check that only one citizenship statement is completed and that the name, signature and date are in place. Download or print the completed PDF from FillingPDF and send it with the rest of your application as described under How to submit.
How to submit Part 1A
Part 1A has no filing channel of its own; it is submitted with the completed Nebraska Lottery Retailer Application by fax or by mail.
- Fax: 402-471-6108.
- Mail: Nebraska Lottery, PO Box 98901 Lincoln, NE, 68509-8901.
For questions about becoming a Nebraska Lottery retailer, call the Nebraska Lottery offices in Lincoln at 800-587-5200 or 402-471-6100 (M-F, 8:00 a.m. - 5:00 p.m.), or email [email protected]. The DOR page also lists the other parts of the application (Parts 1, 2, 3 and 4) and the application instructions. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Completing Part 1A for a business that is not a sole proprietorship; the DOR page says only sole proprietorships need to complete it.
- Marking both the citizen statement and the qualified alien statement; the form presents them as alternatives, separated by "OR".
- Choosing the qualified alien statement but leaving the immigration status and alien number blank.
- Attesting as a qualified alien without being ready to provide a copy of your USCIS documentation upon request, which the statement commits you to do.
- Leaving the SIGNATURE or DATE line empty after printing your name.
- Printing a name that does not follow the first, middle, last order shown under PRINT NAME.
- Sending Part 1A on its own to a different address instead of with the completed application to the fax number or PO Box the Nebraska Lottery lists.
Frequently asked questions
What is the attestation form for a Nebraska Lottery retailer?
It is the United States Citizenship Attestation Form, Part 1A of the Nebraska Lottery Retailer Application. On it you attest that you are a U.S. citizen or a qualified alien under the federal Immigration and Nationality Act, for the purpose of complying with Neb. Rev. Stat. §§ 4-108 through 4-114.
Who has to complete Part 1A of the Nebraska Lottery retailer application?
Only sole proprietorships, according to the Nebraska Department of Revenue's lottery retailer application page. Part 1A is one of five parts; the page lists Parts 1, 2, 3 and 4 as the other forms and asks only sole proprietorships to complete Part 1A.
What do I write if I am a qualified alien?
Choose the qualified alien statement and write your immigration status and alien number on the line provided. By choosing it, you also agree to provide a copy of your USCIS documentation upon request; the form does not ask you to attach it.
Can I fill out the attestation form online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF does not submit it to the Nebraska Department of Revenue or the Nebraska Lottery; you send the completed application by fax to 402-471-6108 or by mail to the address under How to submit.
Where do I send the completed Part 1A?
Send it with the completed application by fax to 402-471-6108, or by mail to Nebraska Lottery, PO Box 98901 Lincoln, NE, 68509-8901. These are the two ways the Nebraska Department of Revenue's page lists for submitting completed applications.
Do I have to sign and date the citizenship attestation?
Yes, the form has a SIGNATURE line and a DATE line below PRINT NAME. By signing you attest that your response and the information on the form and any related application for public benefits are true, complete and accurate.
Who can I call with questions about becoming a Nebraska Lottery retailer?
Call the Nebraska Lottery offices in Lincoln at 800-587-5200 or 402-471-6100, Monday through Friday, 8:00 a.m. to 5:00 p.m., or email [email protected]. These contacts are listed on the Department of Revenue's lottery retailer application page.
Ready to fill out Part 1A?
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