GCVS-2
I
GCVS-2
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
VERIFIED STATEMENT
RAFFLE OPERATIONS
TO REPORT NET PROFITS
LESS THAN $30,000
FOR THE CALENDAR
YEAR:
-,
Instructions: Prepare report in triplicate. Due Januarv 30th of the year following the conduct of a raffle occasion(s). Send
original to clerk of your municipality. one copy to N.Y.S. Racing and Wagering Board and retain one copy for your files.
Organization:
N.Y.S. Identification Number:
Street address:
City:
Date(s) of Raffle Drawing(s):
Zip Code:
County:
A. RECEIPTS (If there is more than one drawing, attach records detailing origin offiguresfor Sections A and B)
1. ~iCk~~mber of tickets printed... ................... .............................................................. ........................... ITITTI
b. Number of tickets sold..................................................... ............................................................... ITITTI
c. Number of tickets unsold... ................. ........ .................. .............. ................................... ................. ITITTI
d. Price of each ticket............................................................................. $ CIIID. CD .
e. Ticket receipts (item I b times item ld)........................................................ $
2. Other Receipts................................................................................ ...... ................ $
3. Total Receipts (Add items Ale and A2)............................................................. $
B. EXPENDITURES - (Only payments directly related to the conduct of the raffle. Attach additional sheets if necessary.)
Describe Expenditure Payee Check No.
1. Total Value of Prizes (Part E).......
2.
3.
4.
5.
$
$
$
$
$
$
$
7. Total Expenditures (Add items B I through B6).................................................. $
C. NET PROFIT OR (LOSS) $
1. Net Profit or (Loss) (item A3 less item B7).........................................................
STOP: If the figure on line Cl is greater than $30,000.00 then you must obtain a raffle license (GC-S) from your municipal clerk and file Form
GC.7R. If the figure on line Cl is less than or equal to $30,000.00 proceed to Section D line 1.
Tickets................................ .... .......
Raffle Equipment & Supplies........
Services........................ ...................
Rent............................................... ..
6. Other Expenses
D. DISPOSITION OF AND ACCOUNTING FOR NET PROCEEDS $
1. Unexpended balance of net proceeds shown on last report..................................
2. Net Profit or (Loss) from this occasion (item Cl)................................................$
3. Interest earned on net proceeds on deposit in interest bearing account( s)........... $
4. Other deposits into or adjustments in Special Games of Chance Account.......... $
Explanation:
L BJ-GCVS-2 (Rev. 4/03) Page 1 of 2
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5. Total Net proceeds (Add items DI through D4)........................................$
Disbursements of Net Proceeds since last report: (Attach additional sheets if necessary)
Date Check No. Description of Disbursements Name & Address of Payee
--,
.LD
Amount
6. Total Disbursements.............. ....................... ........................................................ $
$
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7. Unexpended balance of net proceeds (item D5 less item D6).............................
E. SCHEDULE OF PRIZES (Cash or Fair Market Value of Merchandise Prize(s))
DESCRIPTION OF PRIZES
VALUE
Total Value of Prizes (Report on Line I Part B)......................................................... $
F. SCHEDULE OF DONA TED PRIZES (Cash or Fair Market Value of Merchandise Prize(s))
DESCRIPTION OF PRIZES DONA TED ONLY
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VALUE
Total Value of Donated Prizes........ ............ ........ ................ ......... ....... .... .................... $
G. Grand Total Value of Prizes (Total from Section E plus Section F) $
Note that this amount may not exceed $100,000.00 for the calendar year.................
Instructions: This section must be fully completed by aU parties.
I swear, or affirm that the information and statements contained herein have been examined by me and to the best of my
knowledge and belief are true, correct and complete.
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Street Address City
( ITJJ ) ITJJ - ITIIJ
Phone Number Signature
Member in Charge:
Zip
County
rn/rn/rn
Date
Street Address City
( ITJJ ) ITJJ - ITIIJ
Phone Number Signature
Preparer (if different):
Zip
County
rn/rn/rn
Date
Street Address City
( ITJJ ) ITIJ - ITIIJ
Phone Number Signature
L BJ.GCVS.2 (Rev. 4/03) Page 2 of 2
Zip
County
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Date
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