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Get CT CGF-7

STATE OF CONNECTICUT VERIFIED RAFFLE STATEMENT DEPARTMENT OF CONSUMER PROTECTION CGF-7 Rev. 0 /1 DPLQJ LYLVLRQ Charitable Games Accounting 165 Capitol Avenue Hartford CT 06106 E-mail 3 DPLQJ KDULWDEOH ct. gov Web site www. ct. gov/dcp INSTRUCTIONS 1. The three designated active members of the sponsoring organization must complete this form in duplicate. 2. Submit both copies of this form to the Chief of Police or First Selectman of the municipality which issued such permit during the next succeeding month. 3. The Chief of Police or First Selectman as the case may be shall forward the original copy to the Department of Consumer Protection KDULWDEOH DPHV FFRXQWLQJ at 165 Capitol Ave. Hartford CT 06106 within five 5 business days. NAME OF ORGANIZATION PERMIT NUMBER ADDRESS No* and Street City or Town State CLASS OF RAFFLE HELD RAFFLE DATES WAS THIS A SPECIAL TUITION RAFFLE PLACE AND TOWN WHERE RAFFLE WAS HELD COMMENCING YES / TERMINATING NO AMOUNT OF GROSS RECEIPTS TOTAL EXPENSES GIVE THE NUMBER OF TICKETS SOLD AND THE PRICE PER TICKET Zip Code NET PROFIT OTHER RECORDS FOR ONE 1 YEAR* LIST EACH ITEM OF EXPENSE INCURRED OR PAID AND EACH ITEM OF EXPENDITURE MADE OR TO BE MADE AND THE NAME AND ADDRESS OF EACH PERSON TO WHOM EACH ITEM HAS BEEN OR IS TO BE PAID. EXPENSE/EXPENDITURE NAME AND ADDRESS OF PAYEE AMOUNT LIST THE USES TO WHICH THE NET PROFIT HAS BEEN OR IS TO BE APPLIED PRIZES LIST EACH PRIZE OFFERED 7 5 7 / 9 /8 2 7 2// 56 25 025 THE RETAIL VALUE THE NAME AND ADDRESS OF THE PERSON WHO WAS AWARDED SUCH PRIZE AND THE WINNING TICKET NUMBER* PRIZE OFFERED/AWARDED RETAIL VALUE WINNING TICKET STATEMENT OF PRINTER OF TICKETS NAME OF BUSINESS TELEPHONE NO. BUSINESS ADDRESS No* and Street THE TOTAL NUMBER OF TICKETS WAS THE FIRST NUMBERED TICKET WAS THE LAST NUMBERED TICKET WAS I THE PRINTER OF TICKETS USED IN SAID RAFFLE DO HEREBY STATE UNDER PENALTY OF FALSE STATEMENT THAT THE TICKETS WERE NUMBERED CONSECUTIVELY AND THERE WERE NO DUPLICATIONS* SIGNATURE PRINT NAME DATE STATEMENT OF DESIGNATED ACTIVE MEMBERS AND RANKING OFFICER WE THE UNDERSIGNED DO HEREBY EACH CERTIFY UNDER PENALTY OF FALSE STATEMENT THAT THE FOREGOING STATEMENT IS A TRUE AND ACCURATE REPORT OF THE HOLDING OPERATION AND CONDUCT OF THE RAFFLE DESCRIBED HEREIN* PRINT NAME OF DESIGNATED ACTIVE MEMBER PRINT NAME OF RANKING OFFICER CONCLUSION OF POLICE CHIEF/FIRST SELECTMAN I HAVE EXAMINED THE FOREGOING REPORT AND COMPARED IT WITH THE ORIGINAL APPLICATION* I HAVE FOUND NO DISCREPANCIES I HAVE FOUND THE FOLLOWING DISCREPANCIES SIGNATURE OF POLICE CHIEF/FIRST SELECTMAN TOWN. gov Web site www. ct. gov/dcp INSTRUCTIONS 1. The three designated active members of the sponsoring organization must complete this form in duplicate. 2. Submit both copies of this form to the Chief of Police or First Selectman of the municipality which issued such permit during the next succeeding month. 2. Submit both copies of this form to the Chief of Police or First Selectman of the municipality which issued such permit during the next succeeding month. 3. The Chief of Police or First Selectman as the case may be shall forward the original copy to the Department of Consumer Protection KDULWDEOH DPHV FFRXQWLQJ at 165 Capitol Ave. .

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