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J��te ZJa�i�ma�r+��.cr�� a��2�Ga�14.ariit,,�c <br />(city or town) <br />ANNUAL REPORT - RAFFLES & BAZAARS 411aDh 7 <br />(C. 810, Acts of 1969) ' (date) <br />Name and address of Nonprofit Organization: <br />6-</1bec-Ns-%1se6416pl mvuRzu DFLFlPCL�o�. �i%a �AP6L'al� L��tD�cai/S /yiuscum <br />3�'7Cx.rZ�T NQ'f�. 2d SoucTtl� <br />Expiration Date of Permit: 3�/ 17 <br />Number of Raffles and Bazaars Held: <br />Amount of Money Received: $ <br />Expenses Connected with Raffles Conducted: $ <br />Net Proceeds: $ <br />For What Purposes Were The Proceeds Used? <br />• <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 report is true and complete. <br />2. <br />(Accountant) r. <br />3. <br />Report Certified to be <br />in Conformity With <br />810, Acts of 196 <br />• City/ vn CI rk <br />Signature of Authorized Ofr4r <br />or Member of Organizati <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. 12191 $&W Hoses& WNRREN'N <br />