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FORM 812 110805 6 WARREN INC. <br /> I <br /> �� _ •,� (city or town) <br /> ANNUAL REPORT - RAFFLES & BAZAARS I <br /> (C. 810, Acts of 1969) (date) <br /> Name and address of Nonprofit Organization: <br /> Expiration Date of Permit: ELb• y l <br /> Number of Raffles and Bazaars Held: <br /> Amount of Money Received: $ <br /> Expenses Connected with Raffles Conducted: $ <br /> Net Proceeds: $ <br /> For What Purposes Were The Proceeds Used? <br /> Names & Addresses of Winners of $25. 00 or More: <br /> (Attach Additional Pages as Necessary) <br /> We, the undersigned, do hereby certify that this report is true and complete. <br /> 1. <br /> 2. <br /> (Accountant) <br /> 3. <br /> Report Certified to be <br /> in Conformity With <br /> C. 810, Acts of 1969: � , � <br /> C4CRyMown <br /> Signature of Authorized Officer <br /> or Member of Organization <br /> Clerk <br /> RENEWAL PERMIT WILL NOT BE ISSUED TO LICENSEE UNTIL THIS REPORT <br /> HAS BEEN COMPLETED AND FILED WITH THE COMMISSIONER OF PUBLIC SAFETY. <br /> '' Permit Holders also holdine Beano Licenses,must submit a Coy of this Report to the Massachusetts State Lottery Commission. Revised January 1974 <br />