GC-317
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GC-317
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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
This application must be submitted and approved prior to the expenditure of games
of chance net proceeds for purposes listed under Board Rule 5624.21(C)(4).
Date of Application rn J rn J rn .
Identification Number GC - rn - [ill- UTI - CIIrn
APPLICATION TO
DISBURSE GAMES OF
CHANCE NET
PROCEEDS
1. Name of organization:
2. Mailing Address:
Street
3. Name and address of officer responsible for use of proceeds:
City
State
Zip
Name Street
Phone Number: ([ill ern - ITITI
4. Amount of disbursement for which permission is sought:
5. Describe purpose for which money will be used:
City
State Zip
$
.LD
6. Total unexpended balance on deposit in all bank accounts $
relating to Gaines of Chance:
7. Have you used games of chance proceeds for this purpose in the past year? If so, how much?
8. List other sources of income and amounts per year (See "Note" bottom of page 2):
'.LD
9. Are alcoholic beverages sold on the premises? If yes, attach a copy of price list.
10. Will any of the money you propose to spend be used to erect, equip, maintain or renovate a bar or bar room?_
11. Have you solicited bids for the proposed project? (Submit copies of all bids obtained.)
12. List all disbursements, naming payee, address and amount, made to recognized charities from games of chance
proceeds, commencing one year prior to date of application. (Use separate sheet if necessary.)
13. If funds are to be used for building repairs or new construction, give location of premises where repairs or
construction will be done.
14. Does organization have title to premises?
If not, furnish name of owner.
L BJ-GC-317 (Rev. 4/03)
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15. Has any real property of the organization been sold?
If so, for how much and what disposition was made of the proceeds?
16. List other community activities conducted or to be conducted on premises without charge.
17. How do you plan to finance the repairs or construction?
Give Mortgage terms, if any:
18. List other mortgages or conditional sales contracts outstanding against this property.
19. Has a previous application been filed for this or any other expenditu're?
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I hereby swear (or affirm) that I have read and am familiar with Board Rule 5624.21, and 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.
Name (Signature)
Title
( [II] ) [II] - DID
Phone Number
Print or type name
L BJ-GC-317 (Rev. 4/03)
Page 2 of2
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