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FORM 812 Ii01105 6 WARREN INC. <br /> V <br /> I <br /> - I <br /> www; <br /> (c or town) <br /> ANNUAL REPORT - RAFFLES & BAZAARS <br /> (C. 810, Acts of 1969) (date) <br /> Name and address of Nonprofit Organization: j <br /> Rl9Aj6-S <br /> Expiration Date of Permit: �- !off <br /> Number of Raffles and Bazaars Held: f <br /> Amount of Money Received: $ 306 -2— I <br /> Expenses Connected with Raffles Conducted: $ -2-3 <br /> i <br /> Net Proceeds: $ <br /> For What Purposes Were The Proceeds Used? <br /> I <br /> I <br /> Names & Addresses of Winners of 25. 00 or More: <br /> (Attach Additional Pages as Necessary) <br /> We, the undersigned, do hereby certify that thi report is true an complete. <br /> 2. { <br /> (Accountant) <br /> 3. 1 <br /> Report Certified to be <br /> in Conformity With <br /> C. 810, Acts of 1969: <br /> -�" Signature of Aut orized Officer <br /> 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 1974Holders also holding Beano Licenses,must submit a Copy of this Report to the Massachusetts State Lottery Commission.) Revised January 1974 <br />