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(city or'town) <br />ANNUAL REPORT - RAFFLES & BAZAARS <br />(C. 810, Acts of 1969) <br />Name and address of Nonprofit Organization: <br />TIM <br />Expiration Date of Permit: <br />Number of Raffles and Bazaars Held: A <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 />au IR <br />(Attach Additional Pages as Necessary) <br />We, the undersigned, do hereby certify that this re <br />C�" ,LFA z. <br />(Accountant) <br />--b00'm - <br />Report Certified to be <br />in Conformity With <br />10, Acts of 1(969: <br />1 1 - Signature of Authorized Officer <br />or Member of Organization <br />City/Town CtcrV <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, H&W Homsa WARREN ��' <br />