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/iia ria ee tiiA <br />( ny or tnfvn) <br />ANNUAL REPORT - RAFFLES & BAZAARS d G ljSlo2U 0 % <br />(C. 810, Acts of 1969) date) <br />Name and address of Nonprofit Organization: <br />at / <br />Expiration Date of Permit: 1/un It lb, ,ADO <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 />Names & Addresses of Winners of $500.00 or More: <br />(Attach Additional Pages as Necessary) <br />We, the undersigned, do hereby certify that this repor true and complete. <br />2. <br />(Accountant) <br />Report Certified to be <br />in Conformity With <br />C. 810, Acts of 1969: <br />Signature of Authorized icer <br />ty�aLqor Member of Organ' on <br />•City/Tojyn <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 B12 Rev. H&W Horns A WARREN Tm <br />