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FORM 812 hORRS d WARREN INC. <br /> (city or town) <br /> ANNUAL REPORT - RAFFLES & BAZAARS <br /> (C. 810, Acts of 1969) (date) <br /> Name and address of Nonprofit Organization; <br /> Expiration Date of Permit: 1,�q,90 <br /> l <br /> Number of Raffles and Bazaars Held; VA2t=LQ3) <br /> CSS vi✓�S"s C4.y5hts� <br /> Amount of Money Received: $ 'f,S i 3 .15, J <br /> if <br /> Expenses Connected with Raffles Conducted: $ (i S S°( ' 1 3 <br /> Net Proceeds; <br /> For What Purposes Were The Proceeds Used? <br /> a <br /> 5�. C;t; <br /> Names & Addresses of Winners of $25, 00 or More; <br /> is <br /> I� <br /> (Attach Additional Pages as Necessary) <br /> We, the undersigned, do hereby certify that this report is true and complete. <br /> 2. <br /> (Accountant) �,/ <br /> 3. <br /> Report Certified to be <br /> in Conformity With <br /> C. 810, Acts of <br /> ignature of Authorized Officer <br /> r� or Member of Organization <br /> City/'Town Clerk <br /> RENEWAL PERMIT WILL NOT BE ISSUED TO LICENSEE UNTIL THIS REPORT <br /> i' HAS BEEN COMPLETED AND FILED WITH THE COMMISSIONER OF PUBLIC SAFETY. <br /> (Permit Holders also holding Beano Licenses,must submit a Copy of this Report to the Massachusetts State Lottery Commission.) Revised January 1974 <br />