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0 <br />C7 <br />J� ceo191141zd�� <br />(city or town) <br />ANNUAL REPORT - RAFFLES & BAZAARS /U <br />(C. 810, Acts of 1969) (date) <br />Name and address of Nonprofit Organization: <br />Expiration Date of Permit: / %/2 e <br />Number of Raffles and Bazaars Held: O <br />Amount of Money Received: $ <br />Expenses Connected with Raffles Conducted: $ <br />Net Proceeds: $ <br />For What Purposes Were The Proceeds Used? <br />!✓� K 4.d /io /2/ S GL iN �N,r / Lf�. C;,..t�ys•( . <br />i�T-4,. e-4 <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 />(Accountant) <br />3. <br />Report Certified -to be <br />in Conformity With <br />C. 8 0, Acts of 1969: <br />• CitY/T wn k <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 Slate Lottery Commission.) <br />OVER <br />FORM 812 Rev. 12191 H&W Hoans&WARREN rM <br />