GCVS-1
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GCVS-l VERIFIED STATEMENT
NYS RACING & WAGERING BOARD FOR RAFFLE TICKET
1 Watervliet Ave. Ext., Suite 2 OPERATIONS
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
Instructions: To be issued only for raffles with net profits ofless than $30,000 during a license period (one calendar year).
No fee is required.
Organization:
Street address:
City: Zip Code:
N.Y.S. Identification Number: GC - 0- ITJJ- ITJJ- ITD=rJ
Effective date of raffle license (Calendar Year):
Note: All raffle licenses expire as of midnight December 31st.
Location(s) of raffle drawing(s):
Note: No game of chance shall be conducted on other than the premises of an authorized organization or an authorized
games of chance lessor. [General Municipal Law 189(13)]
Date(s) of raffle drawing(s):
~: This must be a specific date of the actual drawing.
I hereby certify:
1. That the above organization reasonably expects to derive net proceeds or net profits from raffles in an amount'less than $30,000.00
during one occasion or part thereof in the calendar year during which this raffle lease is effective. (An "occasion" is defined as one
calendar year.)
2. That, in the event the organization in fact derives net proceeds or net profits exceeding $30,000.00 during anyone occasion or part
thereof, the above organization shall obtain a license to conduct raffles in accordance with Section 190 of the New York State General
Municipal Law.
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.
President/Officer in Charge Print
President/Officer in Charge Signature
Sworn to before me this
day of
20_
(affix stamp or seal)
Notary Public Commissioner of Deeds
My Commission expires ' 20
TO BE COMPLETED BY THE MUNICIPAL CLERK:
Received and on file with the
Name of Municipality
Municipal Clerk Print
Municipal Clerk's Signature
Date Phone Number
(Clerks: Send one copy of this statement to the organization's licensing municipal clerk, one copy to the New York State Racing and
Wagering Board, and retain one copy to be displayed at all drawings.)
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