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J� C/ <br />(city or -town) <br />ANNUAL REPORT - RAFFLES & BAZAARS <br />(C. 810, Acts of 1969) (date) <br />Name and address of Nonprofit Organization: <br />Expiration Date of Permit: fine- /3, oW <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 <br />/Used? <br />/ld �r/r �o �r /1r� c)c. rnmrn n� X1009 <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 />C. 810, Acts of 1969: <br />� A"M k= — <br />it) To ark <br />report is true co lete <br />1.. <br />i <br />Signature of Aut orized 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 tt&W HOBBBa WARREN To <br />