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FORM 812 IiOBBS d WARREN INC. <br /> (city or town) <br /> ANNUAL REPORT - RAFFLES & BAZAARS �Gf�r�f✓ /y /�Jd <br /> (C. 810, Acts of 1969) (date) <br /> Nameandaddress of Nonprofit Organization: <br /> e rte,t J � �- t��4S T � �►� P� . Q a� 1 drlJy Gl!9-s HPf� <br /> Expiration Date of Permit: O <br /> Number of Raffles and Bazaars Held: /v <br /> Amount of Money Received: $ a <br /> Connected with Raffles Conducted: $__ Zr 77• <br /> Net Proceeds: $ /C 20 Z o, ZO <br /> For What Purposes Were The Proceeds Used? <br /> �o�u��,✓�ayr� Psi��/JOZ.1 ��C /said <br /> Names & Addresses of Winners of $25. 00 or More: <br /> i <br /> i <br /> i <br /> i <br /> (Attach Additional Pages as Necessary) <br /> . I <br /> We, the undersigned, do hereby certify that this report is true and complete. <br /> 1, C <br /> 2. ` <br /> �(Ac�countVn�) <br /> 3. <br /> Report Certified to be <br /> in Conformity With <br /> C. 810, Acts of 1969: <br /> Signature of Authorized C►fficer <br /> ---G-'�J 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 />