instructions for filing the raffle report of operations · the raffle report of operations for the...

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,oremailedtoAskGames@dca.njoag.gov.

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