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FORM 812 I1OR6S 6 WARREN INC. <br /> _ <br /> (cit or town) <br /> n <br /> ANNUAL REPORT - RAFFLES & BAZAARSo�l 1 <br /> (C. 810, Acts of 1969) (date) <br /> Name and address of Nonprofit Organization; j <br /> Expiration Date of Permit: <br /> Number of Raffles and Bazaars Held: oG <br /> t <br /> Amount of Money Received: $ l ? <br /> Expenses Connected with Raffles Conducted: $ C! • U <br /> Net Proceeds: $ ? • S <br /> For What Purposes Were The Proceeds Used? <br /> Names & Addresses of Winners of $25. 00 or More: <br /> r <br /> �l['l(,� , r�' —d 9 1� i ��` Y�7�3 h rhe e wl►4 c� .,�9 <br /> 1 <br /> 21C <br /> (Attach Additional Pages as Necessary) <br /> We, the undersigned, do hereby certify tha this report is true and complete. <br /> 1• --- <br /> (Accountant) <br /> 3 ' <br /> Report Certified to be <br /> in Conformity With <br /> C. 810, Acts of 1969: <br /> re of Authorized Officer <br /> or ember of Organization <br /> City/Town 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 holding Beano Licenses,must submit a Copy of this Report to the Massachusetts State Lottery Commission.) Revised January 1974 <br />