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• rn�s��� <br />(city or [own) //�� <br />ANNUAL REPORT - RAFFLES & BAZAARS I// 6 g <br />(C. 810, Acts of 1969) (date) <br />Name and address of Nonprofit Organization: &7#1ae8-A!'S DF C�RPEeaD =n/C. <br />Fl ba ®EL'oD Cry/ �N't maasrnwnt 's- 71 NerAP-b Sour/; MA aavo44 <br />Expiration Date of Permit: -6kAe <br />Number of Raffles and Bazaars Held: 1 <br />Amount of Money Received: $ ge-Sea <br />Expenses Connected with Raffles Conducted: $ <br />Net Proceeds: $ `5�9 l09 <br />For What Purposes Were The Proceeds Used? <br />• <br />Names & Addresses of Winners of $500.00 or More: <br />(Attach Additional Pages as Necessary) <br />We, the undersigned, do hereby certify that <br />(Accountant) <br />Report Certified to be <br />in Conformity With <br />C. 0, Acts of 1969: <br />n <br />• City/Tow <br />Signature of Authorized Officer <br />or Member of Organization <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.) <br />OVER <br />FORM 812 Rev, (Ji <br />HoBss& WARREN <br />