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GRTR Southern Dutchess COC (2) r GCVS-2 NYS RACING & WAGERING BOARD 1 Broadway Center, Suite 600 Schenectady, NY 12305-2553 Telephone (518) 395-5400 Fax (518) 347-1469 www.racing.state.ny.us VERIFIED STATEMENT RAFFLE OPERATIONS TO REPORT NET PROFITS LESS THAN $30,000 FOR THE CALENDAR YEAR: d 07.) 8' fiECEIVED JAN 3 D 2009 I .'''''',if' TOW"! CLERK N.Y.S. Identification Number: Street address: $ D:JJIQIQIQ]QJ. [00 $ D:JIJII].rn $ ITIIIIIJ.rn $ ITIIIIIJ.rn $ ITIIIIIJ.rn $ ITIIIIIJ.rn $ ITIIIIIJ.rn 7. Total Expenditures (Add items B I through B6).................................................. $ ITIIIIIJ. rn c. ~E~~~~:~~ ~~i~~~~~em A3 less item B7)......................................................... $ ~. caaJ STOP: If the figure on line Cl is greater than $30,000.00 then you must obtain a rame license (GC-5) 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. A. RECEIPTS (If there is more than one drawing, attach records detailing origin of figures for Sections A and B) I. ~iCk~~mber of tickets printed............................................................................................................... ~ b. Number of tickets sold........ ... .... ....... .... ....... ...... ..... ...... ............... .... ..... ..... ... ... ........... ....... .... ... ...... c:r:r:zm c. Number of tickets unsold................................................................................................................ ~ d. Price of each ticket............................................................................. $ [IJ]]QIQJ .1 010 I e. Ticket receipts (item I b times item 1 d)........................................................ $ ~. ~ 2. Other Receipts...................................................................................................... $ o=I=ttffJ. rn 3. Total Receipts (Add items Ale and A2)............................................................. $ ~. [QIQ] 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. Tickets....... ......... ........... ................ 3. 4. 5. Raffle Equipment & Supplies........ Services..... ....................... ............... Rent........... ...................................... 6. Other Expenses D. DISPOSITION OF AND ACCOUNTING FOR NET PROCEEDS $ ITIIIIIJ rn 1. Unexpended balance of net proceeds shown on last report.................................. ~ . 2. Net Profit or (Loss) from this occasion (item Cl)................................................$ ~. [aQJ 3. Interest earned on net proceeds on deposit in interest bearing account(s)........... $ rrrrrr=IQ]. [CJQJ 4. Other deposits into or adjustments in Special Games of Chance Account.......... $ ~ c::a Explanation: L BJ-GCVS-2 (Rev. 3/06) Page 1 of2 11111111111111111111111111111 --1 r I 5. Total Net proceeds (Add items Dl through D4)........................................$ ~. [Q]QJ Disbursements of Net Proceeds since last report: (Attach additional sheets if necessary) Date Check No. Description of Disbursements Name & Address of Payee Amount 6. Total Disbursements............................................................................................. $ o:rrr:IJJ. rn 7. Unexpended balance of net proceeds (item 05 less item 06)............................. $ ITITCrn. rn E. SCHEDULE OF PRIZES (Cash or Fair Market Value of Merchandise Prize(s)) DESCRIPTION OF PRIZES ~-3Qg (h 1 A c -IJ ffj) VALUE $ . $ $ $ Total Value of Prizes (Report on Line I Part B)......................................................... $ ~. [9Q] F. SCHEDULE OF DONATED PRIZES (Cash or Fair Market Value of Merchandise Prize(s)) DESCRIPTION OF PRIZES DONATED ONLY VALUE $ $ $ $ Total Value of Donated Prizes.................................................................................... $ ITCJ:J:IJJ. CD G. Grand Total Value of Prizes (Total from Section E plus Section F) ~ r;-r:;:, Note that this amount may not exceed $100,000.00 for the calendar year................. $ ~. u.LJ12J 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. .----;" /~.s9o Zip b~<2-N~S5 County / I~ I S' I / [QijJ i lC-N L- A5'C~So~ A\!( 1~\;;~I~S ?AIls lJ6?Jo b1L~Ii({':S s(~ ) ~ _ W oWl I ~ Hk~71J-1l?1 / (j Phone Number Signature Date [QIfJ Preparer (if different): Street Address City ( []I] ) []I] - ITIIJ Phone Number L BJ-GCVS-2 (Rev. 3/06) Zip Page 20[2 County LD/ITJ/ITJ Date 11111 III 111111111111 ""11111 -.J Signature Type Check Check Check Check Check Check Check Check Check Check Check Check Check Check Check \:ireater ~outnern Dutcness Cnamber of Commerce, Inc 2008 Raffle Winners NYS 10 # GC.13.21.505.0768 Date 10/02/2008 16914 10/09/2008 16924 10/16/2006 16929 10/23/2006 16930 1 0/30/2006 16952 11/06/2006 16959 11/13/2006 16966 11/20/2006 16972 11/26/2006 16964 12/04/2006 17013 12/11/2006 17016 12/11/2006 1020 12/11/2006 1021 12/11/2006 1022 12/11/2006 1023 Num Name Thomas Digovanni Bob Fisher Rick Zolzer IIaRahilly lee pagones Antalek, Judy Gary Joseph Denise Doring Van Buren Conte, Kristine Carswell, Kevin Robert ledrich Malley, Barbara Quaid, carol Sheila Appel Howell, Steve Memo Weekly raffie prize Weekly raffie prize Weekly raffie prize Weekly raffie prize Weekly raffie prize Weekly raffie prize Weekly raffie prize Weekly raffie prize Weekly raffie prize Weekly raffie prize Raffie-Fourth Prize Grand prize Raffie- 2nd prize split 2nd prize split 3rd prize Amount 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 500.00 5,000.00 1,250.00 1,250.00 1,000.00 10,000.00 10,000.00