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` • C/ "/W �V//V//W'/VLA�I�E�iA�1%V/V iii(/ !./�I%L�%/VWJLVVW <br />i7'lAs�oE�' / <br />(city or town) <br />ANNUAL REPORT - RAFFLES & BAZAARS <br />(C. 810, Acts of 1969) '(date) <br />Name and address of Nonprofit Organization: L�!/it�l2a�s.a�s�ov€-Y mem dF <br />d,44 6VC&A musEu 1n.-5-776'e9P-N&a� Rb VP11 1-! ni�sHAC, M4 d3&te9 <br />Expiration Date of Permit: GLlo/a8 <br />Number of Raffles and Bazaars Held: 0 <br />Amount of Money Received: $ <br />Expenses Connected with Raffles Conducted: $ <br />Net Proceeds: $ <br />For What Purposes Were The Proceeds Used? <br />Names & Addresses of Winners of $25.00 or More: <br />(Attach Additional Pages as Necessary) <br />We, the undersigned, do hereby certify that this <br />(Accountant) <br />Report Certified to be <br />in Conformity With <br />Cr. 8,101 ,, Apc`ttsof 969: <br />City/ ow Clerl ` <br />• <br />(X -4e PNt <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, 12/91 H HoBBs BH/NRREN'" <br />