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FORM 812 LO80S 6 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 /> Cape Cod 4-H Camp Corporation(DBA 4-H Farley Outdoor Educat ' <br /> (Mai 1 ince 1 p 9Boa7 —Center <br /> Forestdale, MA <br /> Expiration Date of Permit:_12/2/89 <br /> Number of Raffles and Bazaars Held: <br /> Amount of Money Received: <br /> $ x,524.00 <br /> Expenses Connected with Raffles Conducted: $ 3 ,370. 64 <br /> Net Proceeds: $ 1 , 153. 36 <br /> For What Purposes Were The Proceeds Used? <br /> Educational activities, programs and supportinfunctions of such <br /> activities andro rams conducted at P g the Center.. in MashP ee. <br /> Names & Addresses of Winners of $25. 00 or More: <br /> $250- Carlene Duprey Fr sPr rt--, Rar»stah� ' 02630 <br /> $250- Emma Causins, 148 Carolyn Dr. , Bellingham, MA 02019 <br /> 9 1 78 <br /> G 1 r.. D __tel i f i(T 02338 2 3 8 <br /> QIlTZr�'V YI�G�7�TTrp X372' L 1 TILL IZTQ.-�/�.Q�-�Ty-.7�V � <br /> $1000-Dorothy Sttodar, RTE 1 86A, Red River Rd. , Gallatin, TN 37066 <br /> I <br /> h (Attach Additional Pages as Necessary) <br /> . I <br /> I <br /> j We, the undersigned, do hereby certify that this report is true and complete. j <br /> 2• <br /> I (Accountant) <br /> j <br /> 3. <br /> Report Certified to be <br /> in Conformity With <br /> C. 810, Acts of 1969: <br /> Signature of Authorized Officer <br /> or Member 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 />