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Wappinger Elks Lodge
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
September 20, 2005
Dutchess County Commissioner of Finance
22 Market Street
Poughkeepsie, New York 12601
Subject: ADD'L. LICENSE FEE - GAMES OF CHANCE
Enclosed is a check in the amount of$33.85 made payable to the D.C.
Finance Commissioner from the Wappinger Elks Lodge #2609, Town of
Wappinger. The additional "License Fee" is for Games of Chance activity
that took place on 8/26/05.
~Cll~
John C. Masterson
Town Clerk
Town of Wappinger
smk
Pay to the .^ ~ 1. ~
Order of VJ U I C/4I[S S' CO. I JlAl!lc€
T II f(~E U'5 10"
A Hudson Yall~y
EHi>., Federal CredIt Umon ...1 ) L
,,........,, eauoHKEEPSIE HY 12SO, 91....3~D1' UJ ~ _ . ~. d
~;rlllg 7g >1:,,':00000000 15bOO~~'; Og~-----"
ROBERT M. ACQUANITA
ANNA R. ACQUANITA
10 VORNDRAN DR.
WAPPINGERS FALLS, NY 12590-4517
@C}arlreflmeric&lJf
50.7936/2219
Date rto!o~~
/ I
COf'{HItX'1. #L.
900
$J.3, a-~""
Dollars
ra1SewnlylM!Wfll;
W:~~bad<
GUARDIAN@SAFETY8LUE WDBL
r
GC-7
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.rncing.state.ny.us
INSTRUCTIONS: Prepare report in triplicate. Within 7 dayS after each license period, send original to clerk of municipality, send one copy to
N.Y.S. Racing & Wagering Board, Bureau of Bell Jar & Charitable Gaming Compliance, 1 Watervliet Ave. ExL, Suite 2, Albany, NY 12206-1668,
and retain one copy for your files. Where applicable, one copy shall also be submitted to the Chief Fiscal Officer of the County.
--,
FINANCIAL STATEMENT
OF GAMES OF CHANCE
OPERA TIONS
(Please Print or Type)
D505
~ it /J.s9 tl
Zip
tf) tJ Ie hfS..s
County
Number of Players
A RECElPTS-
1. Admissions (if fee is charged).........................................
2. Profit or Loss from games other than Merchandi.
3. Profit or Loss from Merchandise Wheel~
(Form GC-7B must be completed ar,
Number of Types of Games
Zip County
~/~/[ili] /,
Date of License Period Hours of License Period
Street Address
4. Total Receipts (Add Items 1,2 and 3).
B. EXPENDITURES - (Show only payments &
Describe Expenditure
ccfi
l
/,'"
.1/
,,~ I"
!;~
2. License Fee
3. Games of Chance Equipment
and Supplies
4. Services cL f.flH //11 G
5. Other Expenses AJ R,U/.. LlcGJlSl
.ICt
I~/'
/?_ {wp
/ f.ACli;'),~D~
'"
;L
.m
. @]Q]
.m
. [iliJ
.~
.m
.[9E
.~
.1815"1
.m
1. Rent
$
$
$
$
tj oS'
.3 10
I
I 0 (p
~ 7 7
3 .3
~ q~
K. Ie. ..,J8t1$R..
R. fiC~UAJI/l1}
6. Total Expenditures. ....... ........... ................. ............. ......... ............... ........ .............. $
C. NET PROFIT OR (LOSS) $
1. Profit or (Loss) Before Additional License Fee (Item A4less Item B6)...............
2. Additional License Fee (UST CHECK NUMBER "0 () )..................... $
3. Net Profit or (Loss) (Item 1 less Item 2)...............................................................$
D. GAME BANK FUND ,Payee Check No. Amount
(Memo Entry Only) L I j}1J To to ff" / 03 "7 oS'. ()O
E. DISPOSmON OF AND ACCOUNTING FOR NET PROCEEDS -
I. If this is organization's first license period. give opening balance, if any, in the $
Special Garnes of Chance Account.......................................................................
Source of opening balance " $
2. Unexpended balance of net proceeds shown on last report..................................
L l\J-GC-7 (Rev. 4/03) Page 1 of 2
.m
8 (p 3 .1 ~ I~ I
11111111111 1111111111111 ~
3. Net profit or (Loss) from this license period (part C, Item 3).............................. $
4. Interest earned on net proceeds on deposit in interest bearing account(s)............ $
5. Other deposits into or adjustments in Special Games of Chance Account............ $
Explanation
I
~ 4 3 .[]li]
.m
.m
r
$
6. Total net proceeds (add Items 1 through 5)..........................................................
Disbursements of net proceeds since last report: (Attach additional sheets if necessary)
i' f.';I "", _ CheckNo. De"",tion of Di,_""ents Nome & Arl","", of Pavee Amonnt
~ loV IJ .Pc.f. lZ'~e-q I Au.lt'. 'OJ/;t'1 7oc. Of)
r.;.~3clCJ !J/HJ1t 5'OIlI( t cJtlJtc ( /J MIl OF fl. y. ;Z1>~(H)
g-':Sl cr ., 1\" ,. ,1 II ~/.tb
/7/cr loS'" ;J.y.t), $'IlU.s 7ftl /'I.ts. SiltS' 1/J1 5"78,'11;
. ~1ii'T/;l r:1i1l)l
7. Total Disbursements............................................................................................ $ U-J. .._~ . ~
8. Unexpended balance of net proceeds (Item 6 less Item 7)................................... $ i (p {p .17 I ~ I
(Include interest bearing accounts)
F. Reconciliation of Unexpended Balance (To be Completed Monthly - - Upon receipt of MonthIy Bank Statement)
Depository Name of Bank Account No. Reconciled Balance
1) Checking 13ft,,, k. 0 t J.IUv y",t k. /:.& 1'18 L/ J 13 III t, ". 7:1....
,
2) Savings
3) Other
Total (Must be the same as Line E8 - Unexpended Balance)............................... $
Instmctions: This section must be fully completed by aD 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.
tJtl'TcbLtK
County
WIl / rn /m
Date
()v7ChE{S
County
[ill] / [l0 / rn
Date
tl!J /J I 'f/J
First Name Last Name
,.!,~ltIdl'-1hJ. IJl cJ,;JlJ.~ /19llS Zip as90
..Lr&ill ) [illTI] - ~ -= or....J,
L BJ-GC-7 (Rev. 4103) Page 2 of2
IJ (iTcJr~
County
01] / 1/ IS-I /1 blsl
Date
1111111111111111111111111 .J
r
GC-7B
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
CASH CONTROL REPORT
GAMES OF CHANCE
-,
Organization: WAf PJ"'Gf~
/iL/Cg _ J.'!~~ ~~O 9 J.D. No.: 13 - ;lJ9 - "-12, -003 Date of License Period:lQm] / ~ / IQ1j
Type of Game Type of Game
No. 1I3J1tc)c..;J/}cI<.. No.2 ::[O}f.,ft /I,~A..
Type of Game
No.3
Number of
Locations
Type of Game Type of Game
No.4 No.5
Number of Number of
Locations Locations
Starting Starting
Bank Bank
Ending Ending
Bank Bank
Number of
Locations ~
Number of
Locations
I
Starting
Bank__~~~P (3
Ending
Bank I;' 0 {,. 00
Starting
Bank /fJo. (YO
Starting
Bank
Ending
Bank 177.0-0
Ending
Bank
~oc ~oc ~oc ~oc ~M
(Loss) 70(,,00 (Loss) 71.00 I (Loss) (Loss) (Loss)
(A) (B) (C) (D) (E)
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
WORKERS WORKERS WORKERS WORKERS WORKERS
(Sl/i. AlTAcJ.J - D )/51')
L BJ.GC-7B (Rev. 4/03)
Page 10f2
CONTROL SUMMARY
PROFIT OR (LOSS)
(A) - II
Game No. 1 If 70 '" , 0 0
(B)-
Game No.2
(C) -
Game No.3
77.00
-
(D) -
Game No.4
-
(E) -
Game No.5
Net Profit
or (Loss)
II 783,00
(Enter on Line A-2 of GC-7)
to iFlil ,Ii C{ft//ftJ/fj}
Prepared By
IIIII~ 1111111111111111111111 --1
r MERCHANDISE WHEELS I-
Merchandise Wheel No. 1 Merchandise Wheel No.5 Merchandise Wheel No.9 CONTROL SUMMARY
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) PROm OR (LOSS
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded--- Less: Value of Mdse. Awarded (A) - Mdse.
Wheel No. 1
Profit or (Loss) Profit or (Loss) Profit or (Loss) (B) - M
(A) (E) (I) W 0.2
- Mdse.
Wheel No.3
Merchandise Wheel No.2 Merchandise Wheel No.6 Merchandise Wheel No. 10 (D) - Mdse.
Wheel No.4
Receipts (Less change bank) Receipts (Less change bank) (E) - Mdse.
Wheel No.5
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded (F) - Mdse.
Wheel No.6
Profit or (Loss) (B) Profit or (Loss) (F) (J) (G) - Mdse.
Wheel No.7
(H) - Mdse.
Merchandise Wheel No.3 Merchandise Wheel No.7 Merchandise Wheel No. 11 Wheel No.8
(I) - Mdse.
Receipts (Less change bank) Receipts (Less change bank) Wheel No.9
(1) - Mdse.
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Wheel No. 10
(K) - Mdse.
Profit or (Loss) Profit or (Loss) Wheel No. 11
(C) (G) (K) (L) - Mdse.
Wheel No. 12
Merchandise Wheel No.4 Merchandise Wheel No.8 Merchandise Wheel No. 12
Receipts (Less change bank) Receipts (Less change bank) Net Profit
or (Loss)
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded
(Enter on Line A-3 of GC-7)
Profit or (Loss) Profit or (Loss)
~ M ~
NTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
L BJ-GC.7B (Rev. 4103) Page 2 of 2
11m 111111111111111111111 --.J
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
-7/L
-::::::=-
September 20,2005
I~
C rFit
Dutchess County Commissioner of Finance
22 Market Street
Poughkeepsie, New York 12601
Subject: ADD'L. LICENSE FEE - GAMES OF CHANCE
Enclosed is a check in the amount of$33.85 made payable to the D.C.
Finance Commissioner from the Wappinger Elks Lodge #2609, Town of
Wappinger. The additional "License Fee" is for Games of Chance activity
that took place on 8/26/05.
()J1l~
~LlI~ .
John C. Masterson
Town Clerk
Town of Wappinger
s111k;
ROBERT M. ACQUANITA
ANNA R. ACQUANITA
10 VORNDRAN DR.
WAPPING~RSFALLS, NY 12590-4517
50-7936/2219
900
Pay to the _^. ~J.
Orderof LJU /epiCS$' CO. "-/Jln/JJc€
-fI Jill' 711/(~z G'S Ie 0 L-
A HudSon Valley
.s:;:.! Federal Credit Union
::------- dl-a--- .. ,4
.: 2 2 .I17I13b 3':00000000 2 5bOO-;;:-~-'----~
Date 'lk~~".
I I
COf'{Hlrrl. $.3.3, i.j--
Dollars m~=
"
r
FINANCIAL STATEMENT
OF GAMES OF CHANCE
OPERATIONS
(Please Print or Type)
-,
GC-7
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
INSTRUCTIONS: Prepare report in triplicate. Within 7 daYS after eacb license period, send original to clerk of municipality, send one copy to
N.Y.S. Racing & Wagering Board, Bureau of Bell Jar & Charitable Gaming Compliance, ] Watervliet Ave. Ext., Suite 2, Albany, NY 12206-1668,
and retain one copy for your files. Where applicable, one copy shall also be submitted to the Chief Fiscal Officer of the County.
M it /).s90
Zip
J) U7C),fSS
County
Zip County
3 ~/~/[ili] /,
Date of License Period Hours of License Period
Admissions (if fee is charged)............................................................................. $
Profit or Loss from games other than Merchandise Wheels................................ $
Profit or Loss from Merchandise Wheels............................................................ $
(Form GC-7B must be completed and attached)
$
4. Total Receipts (Add Items 1, 2 and 3)................................................................
B. EXPENDITURES - (Show only payments actually made)
Describe Expenditure Payee
Check No.
$
$
$
$
$
$
6. Total Expenditures........ ......................... .......... ..... ................................. .............. $
C. NET PROFIT OR (LOSS) $
l. Profit or (Loss) Before Additional License Fee (Item A4 less Item B6)...............
2. Additional License Fee (UST CHECK NUMBER '10() )..................... $
3. Net Profit or (Loss) (Item 1 less Item 2)............................................................... $
D. GAME BANK FUND . Payee Check No. Amount
(Memo Entry Only) L. j}"rOJ.off,' 10.3 7S,vo
E. DISPOSmON OF AND ACCOUNTING FOR NET PROCEEDS -
l. If this is organization's first license period, give opening balance, if any, in the $
Special GanlCS of Chance Account.......................................................................
Source of opening balance . $
2. Unexpended balance of net proceeds shown on last report..................................
L 8J-GC-7 (Rn.4I03) Page 1 of 2
1. Rent
2. License Fee
3. Games of Chance Equipment
and Supplies
4. Services CL~/l}/ING
5. Other Expenses" /jIlt. lJcGltSl
K. ~/TIJ~tlLR..
? AC~UAIIfl1l
0
7 B 3
0
7 (3 :J
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Date
L BJ-GC-' (Rev. oW3)
Page 2 of2
1111111111111 .J
..
r
GC- 7B
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
CASH CONTROL REPORT
GAMES OF CHANCE
...,
Organization: W A P PI,J Gf~
ELk~ jo~e ~'09I.D.No.: J3 -JJ9 -/;c;l -~3 DateofLicensePeriod:~ / ~ / ~
.'.. -..--- __"'_u... _
Type of Game Type of Game Type of Game Type of Game Type of Game CONTROL SUMMARY
No. 113J.1tcJt:['hdc.. No.2 ::rox.rt toisl2. No.3 No.4 No.5 PROFIT OR (LOSS)
Number of Number of Number of Number of Number of (A) - 1/ 706.,00
Locations ~ Locations I Locations Locations Locations Game No. 1
Starting Starting Starting Starting Starting (B) - 7 J. 00
Game No.2
Bank .:5'00 ,0 () Bank /~o . erO Bank Bank Bank
.m___.......,.._...._.._.,."..__.._._~.._.._.__.._.......~ (C) -
-
Ending IJo{,.00 Ending Ending Ending Ending Game No.3
Bank Bank 177.00 Bank Bank Bank
(D) - -
Profit or 70(,,00 Profit or Profit or Profit or Profit or Game No.4
(Loss) (Loss) 71. DO (Loss) (Loss) (Loss)
(A) (B) (C) (D) (E) (E)- -
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY Game No.5
WORKERS WORKERS WORKERS WORKERS I WORKERS
)/SI ') Net Profit II 783,00
(Sid. AlTActJ () or (Loss)
(Enter on Line A-2 of GC-7)
..--.'.----....- ......... -.-._.-._.-..~_.__._--
to iFliT /l CrpU/ffJ/1lJ
L BJ-GC-7B (Rev. 4103)
Page 1 of2
Prepared By
I~ 01111111111111111111111 .J
Profit or (Loss) Profit or (Loss)
~ 00 ~
NTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
L BJ-GC-7B (Rev. 4/03) Page 2 of 2
11111111111111111111 ..J
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
September 20, 2005
Dutchess County Commissioner of Finance
22 Market Street
Poughkeepsie, New York 12601
Subject: ADD'L. LICENSE FEE - GAMES OF CHANCE
Enclosed is a check in the amount of$33.85 made payable to the D.C.
Finance Commissioner from the Wappinger Elks Lodge #2609, Town of
Wappinger. The additional "License Fee" is for Games of Chance activity
that took place on 8/26/05.
~C1/~
John C. Masterson
Town Clerk
Town of Wappinger
smk
P6;~;~~ 61 u Tc/4csS' C ()" "INA/JIe€.
-1I1!?i' J II Jf~E e-5 IDe '-
A Hudson Yall~y
=:,:.i Federal Credit Umon II j L
._'-'~-- UJ ~
~;'2 2 I g? g H. 'I': 00000000 25 ..DO ;';.0 ;OO~ -- -_..~~--...
ROBERT M. ACQUANITA
ANNA R. ACQUANITA
10 VORNDRAN DR.
WAPPINGERS FALLS, NY 12590-4517
@eJarkeAmeri(lll1
50.7936/2219
900 -1
Date r~!e,,j;-
I I
C()f'{H/~1. '11~
$.3J. fj--
Dollars
m~:-
GUARDIAN@SAFETY BLUE WDBl
,
r
GC-'
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
INSTRUCTIONS: Prepare report in triplicate. Within 7 dayS after each license period, send original to clerk of municipality, send one copy to
N. Y.S. Racing & Wagering Board, Bureau of Bell Jar & Charitable Gaming Compliance, I Watervliet Ave. Ext., Suite 2, Albany, NY 12206-1668,
and retain one copy for your files. Where applicable, one copy shall also be submitted to the Chief Fiscal Officer of the County.
FINANCIAL STATEMENT
OF GAMES OF CHANCE
OPERA TIONS
(Please Print or Type)
-,
fA it /;tS9 tJ
Zip
~ t! 'TchL5S
County
Street Address
Zip County
~/~/[ili] /,
Date of License Period Hours of License Period
Profit or Loss from games other than Merchandise Wheels................................
Profit or Loss from Merchandise Wheels............................................................
(Fonn GC-7B must be completed and attached)
Admissions (if fee is charged)............................................................................. $
$
$
$
0
7 B ~5
0
7 B ,j
.~
.m
. [QIQ]
. (Q]Q]
4. Total Receipts (Add Items I, 2 and 3)................................................................
B. EXPENDITURES - (Show only payments actually made)
Describe Expenditure Payee
Check No.
$
$
$
$
$
$
. IT]
. @]QJ
. IT]
'I oS'.~
oS Io.~
. IT]
I 0 (;.[2E]
.~
.181s-1
.m
1. Rent
2. License Fee
3. Games of Chance Equipment
and Supplies
4. Services C L G.fl II IN G
5. OtherExpensesJl. {jUt.. IJcGlIS1
K. /d/TIJIJII-CR..
R. A C~UAH/Tff
6. Total Expendi tures.... .............................. .............. ....... ............. ............. .............. $
C. NET PROFIT OR (LOSS) $
1. Profit or (Loss) Before Additional License Fee (Item A4 less Item B6)...............
2. Additional License Fee (llST CHECK NUMBER 'lOt) )..................... $
3. Net Profit or (Loss) (Item 1 less Item 2)............................................................... $
D. GAME BANK FUND ,Payee Check No. Amount
(Memo Entry Only) L. ~",rOJ.olT/ /0.3 7s'()O
E. DISPOSmON OF AND ACCOUNTING FOR NET PROCEEDS -
1. If this is organization's first license period, give opening balance, if any, in the $
Special GaInes of Chance Account.......................................................................
Source of opening balance . $
2. Unexpended balance of net proceeds shown on last report..................................
L llJ-GC-7 (Rev. 4/03) Page 1 of 2
~ 7 7
3 .3
~ .'1 ..:3
. IT]
e 6; 3 ./' 1..5""
11111111111111111 III II II -.J
3. Net profit or (Loss) from this license period (part C, Item 3).............................. $
4. Interest earned on net proceeds on deposit in interest bearing account(s)............ $
5. Other deposits into or adjustments in Special Games of Chance Account............ $
Explanation
6. Total net proceeds (add Items 1 through 5).......................................................... $
Disbursements of net proceeds since last report: (Attach additional sheets if necessary)
" ~~~I ~ Check No. Description of Disbursements Name & Address of Pavee Amount
~ /0'1 fl.J.'c.l. Jr,)/,,,q lAd. If. #"~{,t'1 70fJ,l>1>
{;.~3clCJ !1/jfoJ1t. ~OiJlt l cIlAJl& ( /J Mil OF f/. y. ;1.1>;b()
t' aiee- ' I 't.1 " 1'1 /. ~/. to
/7/c5" IOS- ;J.y.~. S'/lU~ 7/J-j ".'1S. !}/Jtu I/J~ 5"78'-:18
7. T~tal Disbursements............................................................................................ $~. ~
8. Unexpended balance of net proceeds (Item 6 less Item 7)................................... $ i (P {p .17 12-1
(Include interest bearing accounts)
F. Reconciliation of Unexpended Balance (To be Completed Monthly - - Upon receipt of Monthly Bank Statement)
Depositorv Name of Bank Account No. Reconciled Balance
1) Checking !3IJ.,,,t of: JJ~ y,'ftk. '&>1'1841/3 1I/t".7~
,
2) Savings
3) Other
Total (Must be the same as Line E8 - Unexpended Balance)............................... $
Instructions: This section must be fully completed by all 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.
I
fp -i.J 3 . [[ill
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Date
111111I111111111111111111 .J
r
GC- 7B
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
CASH CONTROL REPORT
GAMES OF CHANCE
I
Organization: W~fPI"'Gf~
/iLler, j~~e ~&."9 I.D.No.: 13 -JI'I -/;0;1. -Q.>I3 DateofLicenseperiod:[QJm / ~ / rn
.....__..-.. -
Type of Game Type of Game Type of Game Type of Game Type of Game CONTROL SUMMARY
No. 1131,u}<.:::rhdc.. No.2 ::JOX€l !6)AA.. No.3 No.4 No.5 PROFIT OR (LOSS)
Number of Number of Number of Number of Number of (A) - # 706.,00
Locations <j Locations I Locations Locations Locations Game No. 1
Starting Starting Starting Starting Starting (B) - 77.00
Game No.2
Bank ..:)00.0 D Bank /fJo.qO Bank Bank Bank
~-----~---- (C) -
-
Ending IJot.oo Ending I 77. 00 Ending Ending Ending Game No.3
Bank Bank Bank Bank Bank
(D) - -
Profit or Profit or Profit or Profit or Profit or Game No.4
(Loss) 70(,,00 (Loss) 71.00 I (Loss) (Loss) (Loss)
(A) (B) (C) (D) (E) (E) - -
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY Game No.5
WORKERS WORKERS WORKERS WORKERS I WORKERS
Net Profit II 783,00
(S€1l )/sT ') I or (Loss)
AlTAct) D
(Enter on Line A-2 of GC-7)
~._,,--,..._._--_... -
RolE/iT /fCrpU/ftJIT}J
L BJ.GC.78 (Rev. 4/03)
Page 1 of2
Prepared By
III IIUIIIIIIIIIII 1111 111111 .-J
Profit or (Loss) Profit or (Loss)
~ ~ ~
NTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
L BJ-GC.7B (Rev. 4/03) Page 2 of 2
~IIIIIIIIIIIIIIIIIIIIIIII .J
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
Septenlber 20, 2005
Dutchess County Commissioner of Finance
22 Market Street
Poughkeepsie, New York 12601
Subject: ADD'L. LICENSE FEE - GAMES OF CHANCE
Enclosed is a check in the amount of$33.85 made payable to the D.C.
Finance Commissioner from the Wappinger Elks Lodge #2609, Town of
Wappinger. The additional "License Fee" is for Games of Chance activity
that took place on 8/26/05.
~C1l~
John C. Masterson
Town Clerk
Town of Wappinger
smk
50.793612219
ROBERT M. ACQUANITA
ANNA R. ACQUANITA
10 VORNDRAN DR.
WAPPINGERS FALLS, NY 12590-4517
900
Date r~~~"
/ I
C()NHlrrlnl"L~ I $JJ. i..s-
Pay to the .A -: J. C ^. '''"/lll9A1CIl'
Order of U U I Clt'C 5' S' v r IV. 1M ~
TilJ!?'Y T IIIt~z ~'0oc ..
,I
A HudSon yan.ey
=::i., Federal CredIt Umon J J L
-_._._~, tv ~
~;'2 2 . q ? q 3 I:. 3': 00000000 251:.0-;;;':' 0 qOO':- " . ,----'---'"
..., SeclJrity Iultltes
W~~~~
Dollars
@GarJreAmerican
GUARDIAN@SAFETY BLUE WOSl
,--
GC-5
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE IkI
BELL JAR 0
RAFFLE 0
GC - [iliJ - WiliJ- [ilili] - ~
N.Y.S. Identification Number
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 License Must Be
Conspicuously Displayed
During Conduct of Games
$1 25..00 II I
Amount of Fee Paid Lessor's License Number
Address: 1195 Route 376 City: Wappingers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable 2/3 Operations
Names of Members in Charge
Paul Bader
Zip Code: 12590
Louis Antolotti
Simon Kaufman
Lev Hakim
UCENSE PERIOD
DATE
8/26/2005
Friday
-_...._..2::./ ~._---_.,.-. -
. - --_...__.-.-_......_-._.-.._~._-- .. OF GAMES
,>-~--..~ ..--...."'...._J--_._.
"'~-'-'-- -..__._.._-_._-,-~--'<-_._..__._-, , "ack
"'--. /-e-L ~ --"~Oker
~c__,._~___''"__~'''__,_..'''.~".
--_"'" _P.. 6.
DAY OF WEEK
RAFFLE DRAWING
DATE
DRAWING TIME
DRA'
_ _._ ~ . r . Wheel
--," .. <V~- -~-:.- .- -."--'-''''.' (Cash or Merchandise Prizes
.___._~ ~ ~ S' at Fair Market Value)
".._--,..~."
-,..---~-"--~~......_-_."'..,,-----,--,.,.."'..._.~_..._...~,..~~-",--"-..,'.~
. """'"'"""""''''---""""",,,,-_,,,,- "'~"""~M .....__ .~.__ "',,""".....
~- --,,,-- ".",- ~- -- ~....~..., -""",..~ ~,......
THE MAXIMUM AMOUNT OF PRIZES TO BE A W
FOR EACH TYPE OF GAME OF CHANCE
$ 500_
NUMBER OF GAMES EACH GAME (Starting Bank)
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
; TOBEAWARDED
$
NUMBER OF WHEELS
EACH WHEEL
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
AuJtUst 18, 2005
(Date)
L BJ.GC.5 (Rev. 4/03)
! '
r
GC-2A APPLICA nON FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (SI8)4S3-846Q Fax (SI8)4S3-8492
www.racing.state.ny.us
-,
Name of Organization
GC- [ili] - [Wfl] - ~ - ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
Uet names, addresses and dates of binh of all officers.
If OI'pIIization is . corporation. or an incol"p(lRted or unincorporated association, Iisl officers and directors.
Tm..E (; NAME ) DATE OF B~TH STREET ADDRESS
I S6d. It-ff/JcUEIJ J../.ST _I _/ _I I
I 1_1_1_' I
I 1_1_1_' I
I 1_1_1_' I
I 1_1_1_1 I
I 1_1_1_' I
I '_1_1_1 I
I '_1_1_1 I
1 1_1_1_1 I
I '_1_1_' I
I 1_1_1_' I
Attach additional sheet if necessary.
~/rn/~
Date
CITY
ZIP
SCHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST POUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
fl*uL ~AdlK.. I-LI ~O 1 ~1---LL-1l';4 ~oRr!~ ~D I~l~ l;k.;'QV
/.a;{S IJHrDk,TT;' I 0 1 2:2/~1-LL.I>>-q RbPJiU~t4J L-NI\!t.}A--(>P,~ t')...~O
$, NIJrJ (Au A.'" I K / ~ / 'bo I-'=L-I "~UrN vi r.; IV u..I.i;f:Q PIl. :r C-'1": I i ~~ ~ ;3
JJ 4J Iftlll.l 1..:1- 1 :KL i ft I ~ I J..~ ~ ~\\1 A-~ L.tIjJ..~ P P:n.u-'7 I (~'8q 0
I 1 I' I I I
'-1-1-' I I I
'-1-1-' I I I
'-1-1-" I I
'=1=1=1 I I I
SCHEDULE 3: AUXlLIARY/AFF1LIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF2 AUXR.IARIESlAFFILIATES. EACH AUXILIARY/AFFD..JAlC LISTED MUST HAVE ITS OWN IU NUMBeR.)
N
ATE
GAMES OF CHANCE ID NUMBER
L BJ-GC.2A (Rev.4J03)
Page) of2
1/111/1/1 1111 " 11111/1111 -.J
A-
U~.~.....i
~ ...
~
&imnul(nufmau 50"235/219
561
fmaEaufmnu 2424
~:U==,~~ill3 D... ~' f, ;)()()Y
~:.~ ~:;~1{.)~~~ I $D.:.~h-~::
THE BANK OF,NEW YORK
ROUTe B2 ~
HOPEWELL JUNCTION, Ny 12533 'T ?-h-c;, 73\
For fi~if;)b; ?,L,I.4~ ~
':0 llo~8~ ~5 ~o: .1I'0~'?y1J~~'~1,1I'
1.';".',
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u
kc ..~.....
lth.1, -. "." .... -
@CHECKGAlLEAV,.1995STYLE'P031_aOO_354.3540 .www.checkgaUery.com
PRINTED ON RECYCLED PAPER USING VEGETABLE-BASED INKS
TOWN CLERK
TOWN OF WAPPINGER
20 MIDDlEBUSH ROAD
WAPPINGERS FAllS. NEW YORK 12590
08694
DATE x;H ~ S
$) ..?51~
DOLLARS
FOR
BALANCE DUE
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
August 9, 2005
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, NY 12601
Dear Sheriff Anderson:
Enclosed, please find a copy of the "members in charge" ofthe Wappinger Elks #2609,
Route 376, Town of Wappinger, who will be conducting Games of Chance on
August 26,2005.
I would appreciate your review of the application and completion of the "Findings and
Determination" form attached.
Thank you for your attention to this request and your prompt reply.
Yours truly,
2:!MM~
Town Clerk
Smk
Enc.
r
GC-4
NYS RACING & WAGERING BOARD
1 Waterv1iet Ave. &t, Suite 2
Albany, NY 12206-1668
Telephone (518)453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC-[ill] - [ill]1J - rillE - ~
N.Y.S. Identification Number ·
-7t?uJAI tJt !JA-I/JIJ/GE~
Name of Municipality
"
S?~
IJ It fJ fJ / ,A/6-t:-..e$
A~"t :)
,/
After investigation, and a hearing if required under Sec. 192 of the General Municipal Law, the foHowing findings and determinations
have been made:
1. All the members-in-ch"ge de<ignared in the applicalion '" conduct games of chance "'" of good moral 0 y" 0 No
character and have never been convicted of a crime.
Title
Signature of Person Conducting Investigation
2. Applicant is a qualified authorized organization as defined in the Games of Chance Licensing Law.
3. All the members designated in the application to conduct games are bona fide active members of the applicant
organization.
4. The premises presently owned or occupied by the applicant !ll'e in every respect adequate and suitable for
conducting games of chance.
5. The games of chance are to be conducted in accordance with the provisions of the Games of Chance Licensing.
Law, the Rules and Regulations of the N.Y.S. Racing and Wagering Board, and local ordinances.
6. The entire net proceeds are to be devoted exclusively to one ore more of the "lawful purposes" as defined in the
Games of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
7. There is satisfactory proof that no commission, salary, compensation, reward or recompense win be paid or
given to any person for conducting the games or assisting therein, except to the extent authorized by the Games
of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
8. There is satisfactory proof that the type and value of prizes offered and gi ven will be in accordance with the
provisions of the Games of Chance Licensing Law.
9. If applicable, the rent to be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
DYes DNa
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
=
\ .
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and detenninations stated above, license is GRANTED 0; license is DENIED 0
Signature of
Filing date of Application Authorized Officer
(Municipal Licensing Authority)
Title
ONE COpy OF TillS FORM TOGETHER WITH ONE COpy OF FORM GC-2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ-GC" (lW. ~3)I\II\11\DI nm 11II II IU Iml ~
Date
r
GC-4
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.lls
I
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC- [Z0 - [illill - ~ - [illillill
N.Y.S. Identification Number .
-TiJ uJ AI tJ! IJ/l-fJ /J AlG E ~
Name of Municipality
Law, the following findings and determinations
e are. of good moral ~s 0 No
"
I'? S'tt?
//f5 L,-f. .J7~
Address
tJlJ-fJfl/Alt:t:--,es FA bl. 5
,/
AI (-I
I
1. All the members-in-charge designated in the ap
character and have never been convicted of cri
Signature of Person Conducting Investigati
Title
2. Applicant is a qualified authorized organizati n as defined in the Games of Chance Licensing Law.
3. All the members designated in the application to conduct games are bona fide active members of the applicant
organization.
4. The premises presently owned or occupied by the applicant ?Ie in every respect adequate and suitable for
conducting games of chance.
5. The games of chance are to be conducted in accordance with the provisions of the Garnes of Chance Licensing.
Law, the Rules and Regulations of the N.Y.S. Racing and Wagering Board, and local ordinances.
6. The entire net proceeds are to be devoted exclusively to one ore more of the "lawful purposes" as defined in the
Games of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
7. There is satisfactory proof that no commission, salary, compensation, reward or recompense will be paid or
given to any person for conducting the games or assisting therein, except to the extent authorized by the Games
of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
8. There is satisfactory proof that the type and value of prizes offered and given will be in accordance with the
provisions of the Games of Chance Licensing Law.
9. If applicable. the rent to be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
~Yes DNa
~Yes DNo
llf'Yes DNo
Ii Y es DNa
iYes DNa
cti Yes DNa
~Yes DNo
00 Yes DNo
DYes DNa
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED f(\; licens
Signature of
Filing date of Application August 9, 2005 Authorized Officer
Date
August 18, 2005
Title
Town Clerk
. ensing Authority)
ONE COpy OF TIllS FORM TOGETHER WITH ONE COpy OF FORM GC-2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ-GC4 (R~. 4103,1\11\ \1\11\ 11\\\ lalll m 111\ -.J
I
GC-5
I
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ex!., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE !Xi
BELL JAR 0
RAFFLE 0
GC - [ili] - [ililiJ- ~ - ~
N.Y.S. Identification Number
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 25~00 II I
Amount of Fee Paid Lessor's License Number
Address: 1195 Route 376 City: Wappingers Fa.lls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable 2/3 Operations
Names of Members in Charge
Paul Bader
Zip Code: 12590
Louis Antolotti
Simon Kaufman
Lev Hakim
LICENSE PERIOD
DATE
8/26/2005
Friday
HOURS
7:00 pm - 1:00 am
TYPE(S) OF GAMES
DAY OF WEEK
Black Jack
Joker Poker
BiR Six Wheel
AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes
at FaIr Market Value)
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$ 500_
NUMBER OF GAMES EACH GAME (Starting Bank)
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
TOWN OF WAPPINGER
(Name of Municipality)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF WHEELS
EACH WHEEL
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STA TE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
AURUst 18, 2005
(Date)
Issued by
L BJ-GC-5 (Rev. 4/03)
I
GC-4
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext, Suite 2
Albany, NY 12206-1668
Telephone (518)453-8460 Fax (518) 453-8492
www.racing.5tate.ny.115
I
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC - 0IJ - [ill]I] - [iliTIJ - ~
N.Y.S. Identification Number ·
-Tt?uJAI tJl IJIl-I/JAlGE ~
Name of Municipality
~
I~S't(J
II f 5 L--f.,g7 ~
Address
tJ fJ- PI / A/6/:--,e5 r A ~/. 5
/'
AlL/
I
After investigation, and a hearing if required under Sec. 192 of the General nni' i Law, the following findings and determinations
have been made: ,/
1. All the members-in-charge designated in the ap . c e are. of good moral /" u! Y es 0 No
character and have never been convicted of cri
Title ~\*
Signature of Person Conducting Investigati
2. Applicant is a qualified authorized organizati n as defined in the Games of Chance Licensing Law.
3. All the members designated in the application to conduct games are bona fide active members of the applicant
organization. .
4. The premises presently owned or occupied by the applicant ?fe in every respect adequate and suitable for
conducting games of chance.
5. The games of chance are to be conducted in accordance with the provisions of the Games of Chance Licensing.
Law, the Rules and Regulations of the N.Y.S. Racing and Wagering Board, and local ordinances.
6. The entire net proceeds are to be devoted exclusively to one ore more of the "lawful purposes" as defined in the
Games of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
7. There is satisfactory proof that no commission, salary, compensation, reward or recompense will be paid or
given to any person for conducting the games or assisting therein, except to the extent authorized by the Games
of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
8. There is satisfactory proof that the type and value of prizes offered and given will be in accordance with the
provisions of the Games of Chance Licensing Law.
9. If applicable, the rent to be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
~Yes DNo
[!j Yes DNo
llf' Y es DNa
00' Yes DNa
iYes DNa
r1i Yes DNa
~Yes DNa
00 Yes DNo
DYes DNo
1 .
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED f(J; licens
Signature of
Filing date of Application August 9, 2005 Authorized Officer
Date
August 18, 2005
Title
Town Clerk
'tensing Authority)
ONE COpy OF THIS FORM TOGETHER WITH ONE COpy OF FORM GC-2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L .,-GC-4 __ 4I03)~1I1 mil In 1\1111\11 m 1m ~
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE ~
BELL JAR 0
RAFFLE 0
GC -lliJ- [ililiJ- ~- ~
N.Y.S. Identification Number
I
GC-S
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.stale.ny.us
I
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 25_00 II I
Amount of Fee Paid Lessor's License Number
Address: 1195 Route 376 City: Wappingers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable 2/3 Operations
Names of Members in Charge
Paul Bader
Louis Antolotti
Si1Ilon Kaufman
Lev Hakim
UCENSE PERIOD
DATE
8/26/2005
DAY OF WEEK
Friday
Zip Code: 12590
HOURS
7:00 pm - 1:00 am
TYPE(S) OF GAMES
Black Jack
Joker Poker
RAFFLE DRAWING
DATE
DRAWING TIME
Bi~ Six Wheel
AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes
at FlIlr Market Value)
DRAWING LOCATION
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$ 500.
NUMBER OF GAMES EACH GAME (Starting Bank)
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3.000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
Au~st 18, 2005
(Date)
L BJ.GC.5 (Rev. 4/03)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF WHEELS EACH WHEEL
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
<\........ '
r
GC-2
-,
FOR OFFICE
USE ONLY
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE)(
BELL JAR 0
RAFFLE 0
$1 dl5.~
Fees Received
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
[ill] I ~ / [lliJ
Date
INSTRUCTIONS: PI.EASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC-[ill-~-I&lol;tl- ~
NY.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
TtJr-J,J of WfiPfl"~FIL /JU TchEC5
Name of Municipality County
L 0 J) G E
2. Address W/t Illtl6h~ HI '-is J N.Y. /.)S1o
3. Has applicant ever been denied a games of chance license? 0 Yes 9'No If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable. give the State and date of incorporation.
COIporation 0
Incorporated Association tI'
Unincorporated Association 0
State incorporated
Date [ill] / 0I] / [tlI]
DateCIJ/CIJ/CIJ
State incorporated
Individual
o
5. Did your corporate status change since your identification number was assigned? 0 Yes )(No
6. Are you doing business under a trade name? 0 Yes pl No If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing( s) are to be conducted. J I q J /IT. J 7 {,
CiJ#hr/6rJ ~Jfllf, AI. y.
.
9. Does the applicant own the premises? 'ji. Yes
/l1fi
/
o No If "yes", how long?
8. Name and address of authorized games of
chance lessor renting to applicant.
10. Capacity for public assembly of premises presently owned or occupied. ,2 3't,
11. Have premises been regularly used? ~ Yes 0 No If "yes", how long? /9 Y F.A1lS
Are games of chance being played now on these premises or has it ever been? .tl Yes 0 No If "yes", give full details.
IJIA,( ;1.00 LI
12. Arc the premises or any part thereof If "yes", state the type of license and number.
where games of chance are to be played ~ Yes 0 No C L .... 00 o7lf ....;243
licensed by the ~~~t)
13. Has such license ever been ,01 j""". nIi '" If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
revoked or suspendepVJG ll'.l~\.;:)Ipo"o
L BJ-GC-2 (Rev. 4103)
TOWN CLERK
Page 1 of2
n111l11U11111111 ..J
.../
~
\
~ -
r
I
PART C. PURPOSES OF GAMES
14. State the ific purposes for which the entire net proc s are to be devoted and in what manner.
I CJ{fJfl"ft~tE J. '.J tJ/.4',RIJT!tJ)1iS
I swear (or affirm):
I. That ALL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shall be devoted exclusively to one or more of the "lawful purposes" as defined in the Games of
Chance Ucensing Law and the Rules and Regulations of the Board.
3. That for each license period for which a license is sought, one or more of the active members under whose supervision the games are to be held,
operdted and conducted, who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S, Racing & Wagering
Board and local licensing ordinances or laws, will be present at all times, in charge and primarily responsible for the conduct of games.
4. That the undersigned will be responsible for the holding, operation and conduct of all games of chance in accordance with the terms of the license,
the provisions of the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering Board and with the provisions
of local licensing ordinances or laws.
5. That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended. the Rules and Regulations
of the N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
6. That no conunission, salary, compensation, reward or recompense will be paid to any person for holding or assisting in the operating or
conducting of the games, except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Board.
I 01 ~I / @f] / I 015'1 f
Date Sign
STATE OF NEW YORK }ss
COUNTY OF :DUTC-H ~.s~
CITY rrOWNNILLAGE OF
S~fht h ~ UR.n ~AJJJt
Print ame
S1rtPH eN .DR613 NIJ K being duly sworn deposes and says that (s)he is the person above named,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personally
affixed his (her) signature to this affidavit.
g1f
Sworn to before me this
:DE:RRlc..l-\ rvf\ lis
Notary Public
day of ~, 20<:JJ
S;gned:OlP~
Commissioner of Deeds
My Commission expires
ID/aI/06
.20~
DERR:CV r' L ::.
f":olary Pu'J':. :, i .' f' ,Yc., r
r;.i ~ '
QU::di,' :n !>'lct. " r. .
e9mmisskl' "'I'''', ,';j ~
L BJ-GC-2 (Rev. 4103)
Page 2 of2
IIIIIIIIIIII~III ..J
"
r
GC-2A
-,
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
APPLICA TION FOR GAMES OF CHANCE LICENSE
GC- [ill] - [ilifi] - [IEE] - [ili0ill]
NYS Identification Number
~ 1 161~1 1 [Q13
Date
SCHEDULE 1:
OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organization is a corporation, or an incorporated or unincorporated association, list officers and directors.
TITLE / NAME ., DATE OF BIRTII STREET ADDRESS
ILS~IZ. ".lfIlcUEIJ t~TJ_I _I _I I
1 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
1 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_' I
1 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
Attach additional sheet if necessary.
CITY
ZIP
SCHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPUCANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTII J}ffiMBERSHIP STREET ADDRESS CITY
ff}{)L tSAd IX. I ~ 1 ~ 1 ~I_J..LJ t, If Rtv'O~~ 1<0 . 1 t.A '-R~l(;rl.~IU<<
~/S /JHro""i7;' I...!!LI ~/20-'--11-I2!:1Ro(l,.i1~U t,fv,. IlvMf' .F4u'? I
S, "'fnJ {,4.v II-tJ 1 L 1 JJL 1 ?:J 0 I ~ 1 q ~~ vt ~W l,. ~. IltO Pti . J"C-I" 1
}J 'V Ift/~ l...l 1 KL 1 ~I '3 I :J...$? Q tJf!l'bV ~ ~A1? f,~ I
1_1_1_1 I 1 I
1_1_1_1 1 1 I
1_1_1_1 1 I 1
1_1_1_1 I I I
1_1_1_1 I 1 I
ZIP
\~ L/ If}
l~>q'O
l ?-S; ~
L r-~q D
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXB..IARIES/AFFILIA TES. EACH AUXB..IARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
N
TE
GAMES OF CHANCE ID NUMBER
L BJ-GC-2A (Rev. 4103)
Page 1 of2
1/1111111111 UIIII -1
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all membe~ of applicant organization and mem~ of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant oJ'Rlltlization or affiliate for at l~ I year.
YEARS OF
MEMBER NAME . rATE OF BIRTH MEMBERSHIP STREET ADDRESS
(SKK fi7TlkH'" ~, , _' _ I _ , I
I , 'I_I 1
1-'-'-'_1 I
1-'-'-1_1 ,
1='='=1_1 ,
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,-,-,-,_, I
1-'-'-'-' I
,-/-,-,_, I
1-'-'-'-' ,
1-'-'-1_1 ,
1-'-'-1_1 ,
'='='=1_1 I
L BJ-GC-2A (Rev. 4103)
Attach additional sheet if necessary.
Page 2of2
-,
CITY
ZIP
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Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2005-2006
Title Name Address Town Zip DOB
-..------------------- --------------- -------------------------- ------------------------------ ------------------------------ ----------, --------------------.
Exalted Ruler Steve Drobnak 53 Moccasin View Rd. Fishkill 12524 02/02/1957
Leading Kgn Pamela Kultsar 58 Hillis Terrace Poughkeepsie 12603 02/01/1950
LoyalKgn Derrick Mills Pawling Lake Box 17 Pawling 12564 10/10/1940
lect. Kgn Sandra Seekamp 67 Pawling lake Pawling 12564 12/10/1945
Esquire Mark H. Fox 28 Tiger Road Hopewell Jct. 12533 09/15/1957
Chaplain Diana M. Cole P.O. Box 549 Hughsonville 12537 04/25/1948
Inner Guard Rosemarie Perretta 35 Cathy Road Poughkeepsie 12603 09/07/1943
Secretary Robert M. Acquanita 10 Vorndran Dr. Wappinger Falls 12590 OS/25/1942
Treasurer Richard O. Desruisseau 183 Red Cardinal Court Poughkeepsie 12603 11/05/1936
Tiler Jacqueline Alfano 93 Brothers Rd. Wappinger Falls 12590 08/27/1938
Trustee Patrick J. Moriarty 26 Robert Lane Wappinger Falls 12590 04/16/1941
Trustee Paul U. Bader 366 Andrews Rd. Lagrangeville 12540 09/20/1965
Trustee Harris Jones 102 Brothers Road Stormville 12582 04/24/1944
Trustee Gerhard P. Stoetzel 662 Noxon Road Poughkeepsie 12603 05/02/1942
Trustee Louis Antolotti 229 Robinson Lane Wappinger Falls 12590 06/23/1933
No Officer receives compensation of any kind.
Schedule 4. Assistants to Members in Charge of Games
First MI
Frank
Philip A.
Ralph J.
Henry J.
Harold A.
Francis J.
Roger
Richard O.
Richard D.
Stephen F.
Robert
Mark H.
Harris C.
Robert J.
Joseph
William K.
Eugene P.
Rosemarie
Gregory F.
Kenneth J.
Robert N.
Last Name
Abato
Abbate
Anzivina
Boldrin
Crawford Sr.
DeGano
DeJordy
Desruisseau
Dobbins
Drobnak
Fischetti
Fox
Jones
Juliano
Jurina
Minkowski PSVP
Pampalone
Perretta
Sarno
Tucker
Wallner
DOB Address
04/24/1940 39 Kensington Drive
05/16/1937 6 Hackensack Hghts Rd
12/21/1935 12 Thorns Lane
01/11/1936 28 Gold Road
02/23/1936 318 Sunset Hill East
07/18/1946 27 Brandy Lane
09/19/1944 83 Kent Road
11/05/1936 183 Red Cardinal Court
05/30/1949 6 Schuele Drive
02/02/1957 53 Moccasin View Rd.
06/07/1926 91 Ardmore Drive
09/15/1957 28 Tiger Road
04/24/1944 217 Brothers Road
10/05/1953 2776 West Main Street
02/28/1963 173 Hillside Lake Rd.
03/20/1942 427 McGrath Blvd.
09/03/1936 53 Helen Drive
09/07/1943 35 Cathy Road
07/01/1936 13 Dana Place
03/19/2029 34 Pawling Lake
01/17/1933 7 Kinry Road
Town
Hopewell Jct
Wappingers Falls
Highland
Wappinger Falls
Fishkill
Wappingers Falls
Wappingers Falls
Poughkeepsie
Wappingers Falls
Fishkill
Wappingers Falls
Hopewell Jct.
Stormville
Wappingers Falls
Wappinger Falls
Fishkill
Wappingers Falls
Poughkeepsie
Wappingers Falls
Pawling
Poughkeepsie
Yrs an Elk
8
15
18
12
15
15
15
18
19
6
25
11
15
10
7
25
17
5
25
6
16
r
GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518)453-8492
www.racing.state.ny.us
I
GC- rn - [iliill- ~ - ~
NYS Identification Number
[Qli] / 10 I:LI / 10 ISI
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPliCABLE FOR BELL JAR GAMES)
. . .
. / .:. 0 .C ~/ pm ! $ ,
, " .., 0 ,& {g. I.... ! $
.., ,am/pm!$ ,
.., ,am/pm! $ ,
.., ,am/pm!$
,., ,am/pm! $ ,
,. ,am/pm! $ ,
,., ,am/pm! $ ,
,.. .am/pm ! $,
.am/pm ! $.
,am/pm! $.
,am/pm! $.
RENT
.0,.,0, O.
DATE
.r, I .02.' ./.0 .~-.! .
.~ .,' .~1
. I .
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./.
./.
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HOURS
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. .
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am / pm -
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am / pm -
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,-.
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RAFFLES
DATE
I
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I
. . .
. . .
am / pm
,
am /pm
.
am /pm
,
am / pm
,
am / pm
,
PRIZES (Cash or Fair Market
Value of Merchandise)
i$. . . . . ... .
i$.
\$
.
$
i$
. .
TIME
am / pm -
. .
am / pm -
. .
am / pm -
. .
am / pm -
. .
am / pm -
. .
SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
CJ.(fJJ/I"IC; KATUlJ R~/rdlJvlA.. tl(, 1t1l€1J~1lk.'fJ lIollf'w$ll
J'(Jilt,L J./C6foiS{ /,4-$7 ~;A1TiA /d;hts /195" fi.7. 17{; u/JII. hills
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STATE
fJ. y.
;J.y.
ZIP
1;2. 573
/.tS9c
L BJ-GC-2B (Rev. 4103)
Page 1 of2
11//11111111111111 -1
r SCHEDULE 7 TYPES OF GAMES 'I
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Veeas Niehts and Bazaars onlv: The total amount of prizes during anyone license period shall not
aggregate more than $400 for each single type of game of chance when five types of games of chance are to be
conducted during anyone license period. The total amount of prizes during anyone license period shall not
aggregate more than $500 for each single type of games of chance when less than five single types of games of
chance are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
fJIAck :rltek.
-To tf IL fb t..1f II..
/Ji ~ Sr) LJ jJ~ If L
LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BANK)
at $ SOO.OD
at
$ ,500. () 0
$ ~oo. 00
$
$
at
at
at
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF THIS APPLICATION
IS FOR A BELL JAR
LICENSE
YESD NO ~
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICATE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESO NO ~
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WlNG(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR-
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT THAT A SINGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
L BJ-GC.2B (Rev. 4103)
Page 2 of2
IIIII~IIIIIIIIIIIIII ..J
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
September 20, 2005
Dutchess County Commissioner of Finance
22 Market Street
Poughkeepsie, New York 12601
Subject: ADD'L. LICENSE FEE - GAMES OF CHANCE
Enclosed is a check in the amount of$33.85 made payable to the D.C.
Finance Commissioner from the Wappinger Elks Lodge #2609, Town of
Wappinger. The additional "License Fee" is for Games of Chance activity
that took place on 8/26/05.
~C-jl~
John C. Masterson
Town Clerk
Town of Wappinger
smk
"
r
GC-2
NYS RACING & WAGERING BOARD
] Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (5] 8) 453-8492
www.racing.statt:.ny.us
-,
APPLICA TION FOR:
PLEASE CHECK
GAMFS OF CHANC~
BELL JAR 0
RAFFLE 0
$1 ~5. If!-
Fees Received
FOR OFFICE
USE ONLY
[Qill / [ill] / @m
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC-[ill. [ID]j]-IG,lol~l- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
'TdCJ,J tJp W,API'I"~I'A.. /JV Tch€C5
Name of Municipality . County
I.
2. Address /;JS1o
3. Has applicant ever been denied a games of chance license? 0 Yes $"No If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and. if applicable, give the State and date of incorporation.
Corporation 0
~w~'
Datc [ill] / @]J] / [ill]
DutCO] / 0] / 0]
Incorporated Association
ti'
State incorporated
Unincorporated Association 0
Individual
o
State incorporated
5. Did your corporate status change since your identification number was assigned? 0 Yes lIf No
6. Are you doing business under a trade name? 0 Yes p( No If "yes", what is the tradc name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to he conducted. / jq r jlT. J 7/;
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? ~ Yes
Lu/lthft/6KJ ;:-"l/f, AI. y,
.
/I#J
I
o No If "yes", how long?
10. Capacity for public assembly of premises presently owned or occupied. ..2. a-- ~
11. Have premises been regularly used? ~Yes 0 No If "yes", how long? /9 YI'A/t.5
Are games of chance being played now on these premises or has it ever been? tI Yes 0 No If "yes", give full details.
fill-It ;1.004
12. Arc the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
13. Has such license ever been 0 0.N
revoked or suspended? Yes U 0
f\E.CE.\\JE:
L BJ-GC.% (Rev. 4103) n 'l~t\~
~\}G t\ ~ /..u
10\J'J~ C\.E.R\<.
.-'
~Yes 0 No
If "yes", state the type of license and number.
C L ... 00 (} 7'1 -,24.3
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
Page 1 of2
I~IIIIIIIII"IIIIIIIIII -.J
v ..________._... ____.____....
r
-,
PART C. PURPOSES OF GAMES
14. State the ific purposes for which the entire net proc s are to be devoted and in what manner.
I Cj(fJ/2IIfi-~ IE. J. '3 "/4;RAT!fJf./S
I swear (or affirm):
]. That ALL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material pan hereof.
2. That the entire net proa:edli of all games of chance shall be devoted exclusively to one or more of the "Iawful purposes" as defined in the Games of
Chance Licensing Law and the Rules and Regulations of the Board.
3. That for each license period for which a license is sought, one or more of the active members under whose supervision the games are to be held,
operdled an<.I conducted, who is fanliliar with the Games of Chance Licensing Law, the Rules and Regulations of the N. Y.S. Racing & Wagering
Board and local licensing ordinances or Jaws, will be present at all times. in charge and primarily responsible for the conduct of games.
4. That the undersigned will be responsible for the holding. operation and conduct of all games of chance in accordance with the terms of the license.
the provisions of the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering Board and with the provisions
of loca1licensing ordinances or laws.
5. That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended. the Rules and Regulations
of the N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
6. That no commission, salary, compensation, reward or recompense will be paid to any person for holding or assisting in the operating or
conducting of the games, except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Board.
I 01 ~I / []I] / 1015'1
Date
L- .-' j) t
~t f v-, r, ((() gAlA
Print ame
ST ATE
OF NEW VORK
CITVffOWNNlLLAGE
OF
}ss
COUNTV
OF 1)u rc.. ri ~ .s ~
S1rtfH eN .DR () 13 N IJ k being duly sworn deposes and says that (s)he is the person above named,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personally
affixed his (her) signature to this affidavit.
(}If-
Sworn to before me this a
:DE:RF?\c..t-\ !Vt'\ lis
Notary Public
day of ~,20'OJ
S;gn<d :Olll~
Commissioner of Deeds
My Commission ex.pires
/',/at/D6
,20~
DERP~C!< r' i ~'
"'otary PUI;!,;:. ~., " .'1 ^'" Yc.if.
fi' .il<'
QU;:l'fi.;.. In I~'.'lct ' '. (' ,0
Commissicii ['<I'I[~'" ,j : .~ j Q...6,
L BJ-GC-2 (Rev. 4103)
Page 2 of2
1111111111111111" 1111111 .J
. ...
r-
GC-2A
--,
NYS RACING & WAGERING BOARD
1 Walervliet Ave. Exl., Suite 2
Albany. NY 12206-1668
Telephone (518)453-8460 Fax (518)453-8492
www.racing.state.ny.us
APPLICA nON FOR GAMES OF CHANCE LICENSE
GC-[ill- 0mJ- ~-~
NYS Identification Number
~/rn/~
Date
SCHEDULE 1:
OFFICERS AND DIRECTORS
Ust names, addresses and dales of birth of all officers.
If organization is . corporation, or BII incorporated or unincorporaled association, liSI officers and directors.
TITI..E ( NAME ) DATE OF BIRTII STREET ADDRESS
I Sa-Ii. "'ffIJcUIi~ J..~T _I _I _, I
-I 1 1 I I
I ___
I '_1_1_1 I
I 1_1_1_' I
I 1_1_1_' I
I 1_1_1_1 I
I 1_1_1_1 I
1 1_1_1_1 I
, 1_1_1_1 I
I 1_1_1_1 I
1 1_1_1_1 I
Attach additional sheet if necessary.
CITY
ZIP
SCHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPUCANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
flluL/JAd tX. I--.1J !l.O / ~1----1L-1 U9 1ltJoR~ ~ p I~ I.Ulf L.1S' qv
/.rotS I9Hro~7Ti' I 0 1 2:21 :?i2.-'--1LI.?J-'1 RtlPJtu ~ttJ L-l\9I~_~_t,..~O
SIf<{(nJ CA." 11-'" I~) ~I 'bo I-LI q ~O {}n~ ul!'1IVL-L.I!I-O pI}. J"crr: , 1~~';:3
}J 4J II-KII4 I.:L 1 ZL 1 ft I ~ I J-~ ~ ~tV If~ L-tl1 ,.\Jj~ P p:ft.tL 7 1 (}sq 0
1 1 1 I I I I
'-1-1-' I I I
'-1-1-1 I I I
'-1-1-' I I I
1=1=1=' I I 1
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
~:L 0F2 AUXILlAIlIES/AFFILIA TES. EACH AUXILlAIlYIAFFILIA 1E USTEO MUST HA VB ITS OWN ID NUM'ER,
N~~TE GAMES OF CHANCE IDNUMBER
L BJ~-2A Olev.4A13) Page] of2 "1~1"11I""""I/1"'111 ..J
r SCIrnDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all mcmber1i of applicanl organization and members of authorized affiliates and auxilial)' who will assist with games. Each person listed must be a
member of applicant ol'Rllllization or amUate for at least I year.
YEARS OF
MEMBER NAME fATE OF BIRTH MEMBERSHIP STREET ADDRESS
(SRIf. j} 7TlkHltJ ~I / _ / _ I _ I ,
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L BJ-GC.2A (Rev. 4103)
Attach additional sheet if necessary.
Page 2 of2
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IrU 1111111/11111 g 1111 .J
CITY
-,
ZIP
Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2005-2006
Title Name Address Town . Zip DOB
----- -------- -------------------------- --------------------- ------------ ---------,
Exalted Ruler Steve Drobnak 53 Moccasin View Rd. Fishkill 12524 02/02/1957
leading Kgn Pamela Kultsar 58 Hillis Terrace Poughkeepsie 12603 02/01/1950
loyalKgn Derrick Mills Pawling lake Box 17 Pawling 12564 10/10/1940
lect. Kgn Sandra Seekamp 67 Pawling lake Pawling 12564 12/10/1945
Esquire Mark H. Fox 28 Tiger Road Hopewell Jct. 12533 09/15/1957
Chaplain Diana M. Cole P.O. Box 549 Hughsonville 12537 04/25/1948
Inner Guard Rosemarie Perretta 35 Cathy Road Poughkeepsie 12603 09/07/1943
Secretary Robert M. Acquanita 10 Vorndran Dr. Wappinger Falls 12590 OS/25/1942
Treasurer Richard O. Desruisseau 183 Red Cardinal Court Poughkeepsie 12603 11/05/1936
Tiler Jacqueline Alfano 93 Brothers Rd. Wappinger Falls 12590 08/27/1938
Trustee Patrick J. Moriarty 26 Robert Lane Wappinger Falls 12590 04116/1941
Trustee Paul u. Bader 366 Andrews Rd. Lagrangeville 12540 09/20/1965
Trustee Harris Jones 102 Brothers Road Stormville 12582 04124/1944
Trustee Gerhard P. Stoetzel 662 Noxon Road Poughkeepsie 12603 05102/1942
Trustee louis Antolotti 229 Robinson lane Wappinger Falls 12590 06/23/1933
No Officer receives compensation of any kind.
Schedule 4. Assistants to Members in Charge of Games
First MI
Frank
Philip A.
Ralph J.
Henry J.
Harold A.
Francis J.
Roger
Richard O.
Richard D.
Stephen F.
Robert
Mark H.
Harris C.
Robert J.
Joseph
William K.
Eugene P.
Rosemarie
Gregory F.
Kenneth J.
Robert N.
Last Name
Abato
Abbate
Anzivina
Boldrin
Crawford Sr.
DeGano
DeJordy
Desruisseau
Dobbins
Drobnak
Fischetti
Fox
Jones
Ju~ano
Jurina
Minkowski PSVP
Pampalone
Perretta
Sarno
Tucker
Wallner
DOB Address
04/24/1940 39 Kensington Drive
05/16/1937 6 Hackensack Hghts Rd
12/21/1935 12 Thorns Lane
01/11/1936 28 Gold Road
02/23/1936 318 Sunset Hill East
07/18/1946 27 Brandy Lane
09/19/1944 83 Kent Road
11/05/1936 183 Red Cardinal Court
05/30/1949 6 Schuele Drive
02/02/1957 53 Moccasin View Rd.
06/07/1926 91 Ardmore Drive
09/15/1957 28 Tiger Road
04/24/1944 217 Brothers Road
10/05/1953 2776 West Main Street
02/28/1963 173 Hillside Lake Rd.
03/20/1942 427 McGrath Blvd.
09/03/1936 53 Helen Drive
09/07/1943 35 Cathy Road
07/01/1936 13 Dana Place
03/19/2029 34 Pawling Lake
01/17/1933 7 Kinry Road
Town
Hopewell Jct
Wappingers Falls
Highland
Wappinger Falls
Fishkill
Wappingers Falls
Wappingers Falls
Poughkeepsie
Wappingers Falls
Fishkill
Wappingers Falls
Hopewell Jct.
Stormville
Wappingers Falls
Wappinger Falls
Fishkill
Wappingers Falls
Poughkeepsie
Wappingers Falls
Pawling
Poughkeepsie
Yrs an Elk
8
15
18
12
15
15
15
18
19
6
25
11
15
10
7
25
17
5
25
6
16
or'
GC-2B APPLICA TION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
1 Willer-vliet. Ave, Exl,. Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
GC- rn - [WIT] - ~ - ~
NYS Identification Number
[Qli] / rn / /0 15-1
Date
SCHEDULE 5 DA TES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT A.PPUCABLE FOR BELL JAR GA.MES)
DATE
S- / ,ti1.(; /.0 5"! ,
,~ " ,.)7 .,', J r I ,
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,/ , . / , .1 ,
/ . / I
RAFFLES
DATE
HOURS
7:,ooam@-
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.
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,
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.
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.
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/ :, 0 ,,~/ pm ! $ .
/ "'u ,J (9.'1.... !$ ,
,', ,am/pm 1$.
. . am / pm ! $ .
,'. am/pm '$.
,', ,am/pm $ ,
'. am/pm $ ,
.', .am/pm $.
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o. am/pm $ ,
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"0 ,am/pm $ ,
RENT
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PRIZES (Cash or Fair Market
Value of Merchandise)
$,
:$
,
'$
,
$
$
"
TIME
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SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
CJ..IA ill" IG KA7Ull ,?I:,rdAvtll.. ;~ hllt=~4t>flk.t' !lo!K'wrll
J/ficJeL )/C6,.JS( /"'$7 ~Y.~1 Tt8 !<uUP /I <15 j.l. 77& U/JII. hillS
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STATE
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L BJ-GC-2B (Rev. 4103)
Page 1 of2
I~II" IIIIIII~ 1I1~1I11 -1
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I
. r SCHEDULE 7 TYPES OF GAMES --,
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for VeRBS Nhzhts and Bazaars onlv: The total amount of prizes during anyone license period shall not
aggregate more than $400 for each single type of game of chance when five types of games of chance are to be
conducted during anyone license period. The total amount of prizes during anyone license period shall not
aggregate more than $500 for each single type of games of chance when less than five single types of games of
chance are to be conducted during anyone license period.
UST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
/JLA C Ie. :::rf) C "-
:To t..f Ii. fb t..L /I..
AI ~ SrI. WJii,f L
LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BANK)
at $ So 0 . 0 ()
at $ .500. Co
at $ S-OO. 00
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF THIS APPLICATION
IS FOR A BELL JAR
LICENSE
YESO NO ~
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICA TE IF THIS APPLICA nON
IS FOR A RAFFLE
LICENSE
YES 0 NO rf..
IF YES, LIST RAFFLE DATES, TlME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCfED DUR-
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT THAT A SINGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
L BJ-Gc.m (Rev. 4.1)3)
Page 2 of2
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