instructions for filing the raffle report of operations · the raffle report of operations for the...
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New Jersey Office of Attorney GeneralDivision of Consumer Affairs
Legalized Games of Chance Control Commission124 Halsey Street, 6th Floor, P.O. Box 46000
Newark, New Jersey 07101(973) 273-8000
Instructions for Filing the Raffle Report of Operations PursuanttoN.J.A.C.13:47-9.1,licenseesmustfileareportofoperationswiththeLegalizedGamesofChanceControlCommissionnolaterthanthe15thdayofthecalendarmonthimmediatelyfollowingthecalendarmonthinwhichthelicensedactivitywasheld,operatedorconducted.
YoumustdownloadthisreportandcompleteALLoftheentriesforeachoccasion(s)relatingtotheconductofallraffles,exceptforinstantrafflegamesandcarnivalgamesandwheels.Oncecompleted,amember/officermustcertifythathe/shehasreviewedthereportandthattheinformationprovidedistrue,accurateandcomplete.Thiswillrequirethepersontostatehis/hernameandtitle,andthatpersonmustcompletetheinformationonpage3andhavethereportnotarized.
TheRaffleReportofOperationsfortheconductofoff-premises50/50ormerchandiserafflesistobeaccompaniedwithasampleticket.ReportsaretobemailedtoLegalizedGamesofChanceControlCommission,P.O.Box46000,Newark,NewJersey07101,[email protected].
Itisrecommendedthatyoumaintainacopyofallreportsaspartoftheorganization’srecords.
New Jersey Office of Attorney GeneralDivision of Consumer Affairs
Legalized Games of Chance Control Commission124 Halsey Street, 6th Floor, P.O. Box 46000
Newark, New Jersey 07101(973) 273-8000
Raffle Report of Operations
Please print clearly.Identificationnumber (format ###-##-#####) _____________________
Municipality______________________________________ Licensenumber______________________
Nameoflicensee_____________________________________________________________________________Organization
___________________________________________________________________________________________Streetaddress City State ZIPcode
Locationofgames____________________________________________________________________________
This report, as required byN.J.S.A. 5:8-37 andN.J.A.C. 13:47-9,must befiledwith theLegalizedGamesofChanceControlCommissionnolaterthanthe15thdayofthemonthfollowingtheconductofthegame(s)ofchance.
Occasion 1 Date ____________________Time_____________________ Typeofraffle______________
1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________
Occasion 2 Date ____________________Time_____________________ Typeofraffle______________1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________
Occasion 3 Date ____________________Time_____________________ Typeofraffle______________1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________
Occasion 4 Date ____________________Time_____________________ Typeofraffle______________1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________
Occasion 5 Date ____________________Time_____________________ Typeofraffle______________1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________
Occasion 6 Date _______ Time_________ Typeofraffle _________
1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________(Ifneeded,attachseparatesheet)
7.Totalexpenses $__________ 8.Netproceeds $_________
Totalnumberofoccasions.................................. _________Totalnumberofticketssold(1-6combined)...... _________ Priceoftickets..................................................... $ ________ Totalgrossproceeds(1-6combined).................. $ ________ Totalexpenses(1-6combined)........................... $ ________ Totalnetproceeds(1-6combined)...................... $ ________
Date
Schedule of Expenses
Description Checknumber Amount
Date
Utilization of Net Proceeds
Description Checknumber Amount
Name
Bank
Addresswherebalanceisdeposited Accountnumber
Name
Person Responsible for Use of Proceeds
Address Telephonenumber(includeareacode)
Icertifythatallofthestatementsonthisreportofoperationsaretrue,accurateandcomplete.Iamawarethatifanyoftheforegoingstatementsarewillfullyfalse,Iamsubjecttopunishment.
N.J.S.A.5:8-37“Itshallbethedutyofeachlicenseetomaintainandkeepsuchbooksandrecordsasmaybenecessarytosubstantiatetheparticularsofeachsuchreport.”
I certify that I have reviewed this report and that the informationon this report of operations is true,accurateandcomplete.Iamawarethatifanyoftheforegoingstatementsarewillfullyfalse,Iamsubjecttopunishment.
I certify by placing a check in this box, that I have reviewed the report and that the information provided is true, accurate and complete.
Youmuststateyournameandtitlebelow.Reportsthatarenotproperlycertifiedwillbeemailedback.
_______________________________________ __________________________________________Nameandtitleofofficer(pleaseprint) Signatureofofficer
Swornandsubscribedtobeforemethis__________dayof ______________________ ,____________
__________________________________________ NameofNotaryPublic(pleaseprint)__________________________________________SignatureofNotaryPublic
MonthYear Affix Seal Here
Form LGCCC 8R-A (Rev. 4/6/16)
Prizes Offered or AwardedPleaselisttheprizesofferedorawardedandtheirrespectiveretailvalues.
PrizesOfferedorAwarded RetailValue PrizesOfferedorAwarded RetailValue