New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.3 - Personal History Disclosure Form 1

Universal Citation: NJ Admin Code 13:69A-5.3

Current through Register Vol. 56, No. 18, September 16, 2024

(a) A Person History Disclosure Form (PHD-1) shall be in a format prescribed by the Division and may require the applicant to provide the following information:

1. Name, including maiden name and any aliases or nicknames along with applicable dates of usage;

2. Date and place of birth;

3. Physical description;

4. Current address and telephone number, and residence history for the past 10 years;

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, country of which the applicant is a citizen, place of birth, port of entry to the United States, and name and address of sponsor(s) upon the applicant's arrival;

7. Reason for filing the PHD-1;

8. Marital history and other family data;

9. Employment history, including any gaming-related employment, for the past 10 years;

10. Education and training;

11. Record of military service;

12. Licenses and other approvals held by or applied for by the applicant or, where specified, the applicant's spouse, in this State or any other jurisdiction, including:
i. Any license, permit, approval or registration required to participate in any lawful gambling operation in this State or any jurisdiction;

ii. Any denial, suspension or revocation by a government agency in this State or any other jurisdiction of a license, permit, approval or registration held by or applied for by the applicant or the applicant's spouse; and

iii. Motor vehicle registrations and operator licenses held by or applied for by the applicant or the applicant's spouse, and any revocation or suspension thereof;

13. Civil, criminal and investigatory proceedings in any jurisdictions, as follows:
i. Arrests, charges or offenses committed by the applicant or any member of the applicant's immediate family;

ii. Any appearance before, investigation by or request to take a polygraph examination by any governmental agency, court, committee, grand jury or investigatory body; and

iii. Lawsuits to which the applicant was or is a party in the past ten years; and

14. Financial data, as follows:
i. All assets and liabilities of the applicant, and the applicant's spouse and dependent children as indicated on the net worth statement and supporting schedules in a format prescribed by the Division, including cash, bank accounts, notes payable and receivable, real estate and income taxes payable, loans, accounts payable, credit card debt and any other indebtedness, contingent liabilities, securities, real estate interests, real estate mortgages and liens, life insurance, pension funds, vehicles and other assets;

ii. Bank accounts, including any right of ownership in, control over or interest in any foreign bank account during the last ten year period as well as with regard to safe deposit boxes;

iii. Real estate interests held by the applicant or the applicant's spouse or dependent children in the past 10 years regardless of whether such interest was held under a recorded or unrecorded instrument;

iv. Any business in which the applicant has held an ownership interest for the past 20 years;

v. Copies of Federal and New Jersey tax returns and related information for the last five years;

vi. Judgments or petitions for bankruptcy or insolvency concerning the applicant or any business entity in which the applicant held a five percent or greater interest, other than a publicly traded corporation, in the past 20 years or in which the applicant served as an officer or director;

vii. Any garnishment or attachment of wages, charging order or voluntary wage execution, during the past 10-year period including the amount, court, nature of the obligation and the name and address holder of the obligation;

viii. Positions held or interest received in any estate or trust during the last 10-year period;

ix. Insurance claims in excess of $ 100,000 by the applicant or the applicant's spouse or dependent children filed within the past 10-year period;

x. Loans in excess of $ 10,000 made or received by the applicant, the applicant's spouse or dependent children in the last 10-year period;

xi. During the last five-year period, any gifts in excess of $ 10,000, either individually or in the aggregate, given or received, whether tangible or intangible, by the applicant or the applicant's immediate family in any one-year period; and

xii. Referral or finder's fees in excess of $ 10,000 in the past 10 years.

(b) In addition to the information in (a) above, a completed PHD-1 shall include the following:

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

2. 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.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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