GRTR Southern Dutchess COC
I I
GCVS-l VERIFIED STATEMENT
NYS RACING & WAGERING BOARD FOR RAFFLE TICKET
I Broadway Center, Suite 600 OPERATIONS
Schenectady NY, 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
Instructions: To be issued only for rames with net profits of less than $30,000 during a license period (one calendar year).
No fee is required.
Organization: .8 0 tJ... g t f!... N
Street address: ~ 5 ~J. ~~ A V~
City: tJJAp p If{~eec., ~ ll~ I I I I -" I I I I Zip Code:
N.Y.S. Identification Number: GC - c::z:I3J- [2JJE- ~- ~
Effective date ofraffie license (Calendar Year): ';<00 g
Note: All rame licenses expire as of midnight December 31st.
j as! (J
Location(s) ofraffie drawing(s): l):5S b I ('J( (L ~ l)..,~ ol\ (\6 So ~ Il/l- Wr<1
~: No game of chance shall be conducted on other than the premises of an authorized organization or an autHorize
games of chance lessor. [General Municipal Law 189(13)]
Date(s) ofraffie drawing(s): Dt~M 6>62- I I { {}-DO~
~: This must be a specific date of the actual drawing.
1 herebv 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 raffie lease is effective. (An "occasion" is defined as one
calendar year.)
~115
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 raffies in accordance with Section 190 of the New York State General
Municipal Law.
or affirm) that the information and statements contained herein have been examined by me and to the best of my knowledge and
e t e, corr. ct and complete.
Ar-JrJ
M M{A&~d--
President/Officer in Charge Print
\....,,,
President/Officer in Charge Signature
. 't1A..
Sworn to before me this I )
fQN'k~ 20~
issioner of Deeds
I I d-d--
I
TO BE COMPLETED BY THE MUNICIPAL CLERK:
~A.~eal)
Not8ly PublIc, Statt of NewYort
No.01MI811112t
QuIIIIIed In Outa.a COU'IlY
Term ExpIrelS Ja....ry 22, 2012
My Commission expires
, 20J~
Received and on file with the h H\V'P It.. )GE R..
Name of Municipality
:1DH(\ C. Mf\~~~O(l
icipal Clerk's ignature Munic~i al Clerk Print
v 9/l\1.9-8~g- (~L(~ ::r11-) 77 f
~ Phone umber
(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.)
L W-GCVS-l (Rev. 3106) 1111111111111111I1111111111I1 --.J