Application Package Raffle Licence Requirements

111 Erie Street North, Leamington, ON, Canada N8H 2Z9
Telephone (519) 326-5761  Fax (519) 326-2481
Brenda M. Percy, Manager of Legislative Services/Clerk
Email: [email protected]
Application Package
Raffle Licence Requirements
Please read the following carefully:

Your completed application and your cheque payable to the Municipality of Leamington
in the amount of 3% of the value of the prize is to be submitted at least three (3)
business days prior to the date you plan to order your raffle tickets.

The market retail value of the prize(s) to be awarded shall not be less than 20% of the
anticipated gross receipts from the sale of the tickets calculated on the total number of
tickets expected to be sold multiplied by the price per ticket as approved on the licence
application.

The value of the prize(s) shall include the amount of any duty, tax, sales tax or other
cost that may be in addition to the base purchase price of the prize, and shall be paid
by the licensee. Prize(s) shall be awarded free and clear of any mortgage, lien or any
other encumbrances.

Where the prize(s) has a value over $10,000.00 legible copies of a firm price quotation,
invoice, or agreement to purchase, are to be obtained and made available to the
Municipality.

An irrevocable Letter of Credit may be required for the full prize value from charities
conducting raffle lotteries with a prize value over $10,000.00.

Rules of Play are to be included with the completed application (see attached Sample
Rules of Play).

No person under the age of 18 may purchase raffle tickets. The Ontario Gaming
Commission (AGCO) recommends that no person under 18 be allowed to sell tickets.

The attached AGCO Lottery Report must be filed within 30 days of the date of the last
draw and returned to the Leamington Municipal Office, Attention Lottery Licensing.
2

Those applying for a lottery licence shall provide a sample ticket with their application.
The raffle licence number must be printed on your raffle tickets (see below).
Note: A licence number for the raffle lottery will not be provided until the licence has been
approved by the licensing authority. Printers will be able to provide a sample to accompany
your application and will add the Licence number after your application is approved.
Lottery Report after Event
In addition to the Lottery Report please be sure to forward the following information to the
Municipality to ensure the raffle conducted is according to the (AGCO):





List of winners and their telephone numbers
Copy of any advertisements used
Copies of all deposits made to lottery trust account
Does the number of tickets printed agree to application?
Is your advertisement of the winners in accordance with the application?
It should be noted that it is the licensee’s responsibility to know the “Terms and Conditions”
and policies set forth by the Registrar of the Alcohol and Gaming Commission of Ontario.
A copy is provided to you with your Raffle Application and Raffle Report.
For further assistance contact Mary Ann at 519-326-5761 extension 1110 or at
[email protected]
“T:\Corporate\P00-Protection&Enforcement\P09-Licencing\P09-Lotteries\Raffle\Forms\Application Package Raffle Licence
Requirements.doc
111 Erie Street North, Leamington, ON, Canada N8H 2Z9
Telephone (519) 326-5761  Fax (519) 326-2481
Brenda M. Percy, Manager of Legislative Services/Clerk
Email: [email protected]
Sample Rules of Play
This information is intended as a guide only.
Those applying for a lottery license shall provide “rules of play” with their applications.
Rules of play shall indicate the detailed procedures to be followed for all draws and for all
prizes to be awarded. Rules of play shall be made available to ticket purchasers if
requested. The following information will assist lottery applicants develop rules of play.
Sample Raffle Draw Details:
Participants may purchase a lottery ticket for a chance to win one of 4 prizes worth a total
value of $5000.00.
The prizes will be awarded according to the following schedule:




1st ticket drawn wins $250.00 cash
2nd ticket drawn wins $500.00 cash
3rd ticket drawn wins $1250.00 cash
4th ticket drawn wins the Grand Prize trip to Mexico worth $3000.
Before each ticket is drawn, the tickets within the drum will be spun five times. Winning
tickets will be placed back in for a chance to win the grand prize.
Sample 50/50 Rules of Play:
Location, event and time of draw i.e. ABC Hockey Association 50/50 tickets to be drawn
during second intermission during hockey games on the first and fifteenth of each month,
from January to March.
The ticket purchaser deposits ticket(s) in the raffle barrel/box. Tickets are mixed up three
times before ticket drawn.
The first ticket drawn will be considered the winning ticket and announced. However, in the
event a winner does not come forward to claim the prize, the ticket number will be
announced again after waiting one minute it will be announced the third time should no one
claim. Another ticket will then be drawn and the same process used until a winner has
claimed;
Winner wins 50% of the total collected for the 50/50 draw to a maximum prize value of
$300.
Penny Draw Details:
For $2.00, participants purchase 10 tickets which are detachable from the stub portion
(retained by the purchaser). Participants may enter as many tickets as they possess on
any item (prize) they are interested in by depositing the tickets into a container assigned to
that item (prize). The item (prize) is awarded to the person whose ticket is drawn, at
random, from the container. The container is shaken three times prior to drawing the ticket.
2
The raffle is limited to a maximum prize board of $500 and individuals must be present to
win.
Elimination Draw Details:
Participants may purchase a lottery ticket for a chance to win one of six prizes worth a total
value of $10000.00. Before the start of the draw, the drum containing the tickets will be
spun ten times. The prizes will be awarded according to the following schedule:






1st ticket drawn wins $100.00 cash
5th last ticket drawn wins $250.00 cash
4th last ticket drawn wins $750.00 cash
3rd last ticket drawn wins $1250.00 cash
2nd last ticket drawn wins $2650.00 cash
Last ticket drawn wins $5000.00 cash
For further assistance contact Mary Ann at 519-326-5761 extension 1110 or at
[email protected]
“Building on the Past . . . Preparing for Future Prosperity.”
Alcohol and Gaming Gommission of 0ntario
Gaming Registration & Lotteries
90 SHEPPARD AVENUE EAST SUITE
TORONTO
ON M2N
2OO
OA4
AGCO
Alcohol and Gaming
Commission of 0ntario
Tel.:416 326-8700
Ontarlo
Farc 416 326-5555
1 800 522-2876 toll free in 0ntario
Website: www.agco.on.ca
Raffle Licence
Têrms and Conditions
DEFINITIONS
bona fide member means a member in good
standing of the licensee who has other duties,
beyond conducting lotteries, within the organization. "Members of conven¡ence" whose only duty
is to assist with the raffle lottery are not considered bona fide members.
books and records means documents outlining
financial details of lottery events and includes,
but is not limited to, ledgers, sub ledgers, cheque
books, cheque stubs, deposit books, deposit slips,
bank statements, cancelled cheques, receipts,
invoices, and control sheets.
licensee means an organization which has been
issued a licence to conduct a lottery under Section
207 o'f the Criminal Code.
licensing authority means a person or authority
specified by Lieutenant Governor in Council as a
licensing authority for purposes of section 207 of
the Críminal Code of Canada.
raffle means a lottery scheme where tickets are
sold for a chance to win a prize at a draw, and
includes 50/50 draws, elimination draws, calendar
draws, sports raffles and "rubber duck" races.
Registrar means the Registrar of Alcohol and
Gaming.
Any raffle licence issued is subject to the following terms and conditions and the Loltery Licence
Terms and Conditions (42401and may be subject
to audit and investigation by the licensing authority. A breach of any term and condition can result
in the cancellation or suspension of the licence or
in prosecution.
It is a condition of each licence that
60044 E (2015/06) @ Queen's Printer of Ontario, 2015
(1}
GENERAL
1.1
The licensee is responsible and accountable for the overall management and
conduct of the raffle.
1.2
The licensee must control and decide all
operational, administrative and staffing
requirements related to the conduct of the
raffle.
1.3
The licensee must comply with all federal,
provincial and municipal laws including the
Criminal Code of Canada and the Gaming
Control Act, 1992 and Regulations.
1.4
The licensee must conduct the raffle ín
accordance with the information supplied
on the application and approved by the
licence.
1.5
The licensee must produce the licence on
demand.
l2l
STAFFING
2.1
The licensee must designate at least two
(2) bona fide active members to be in
charge of and responsible for the conduct
of the raffle.The designated members in
charge must be at least 18 years of age and
be responsible for:
a)
supervising all activities related to the
conduct of the raffle;
b) completing and filing the required
financial report on the results of the event;
c)
ensuring that allterms and conditions
of the licence and any additional conditions
imposed by the licensing authority, are
complied with;
Disponible en Français
Page 1 of 5
d) supervising all ticket sellers;
¡¡.
e)
¡¡¡. the location(s), date(s), and
time(s) of the draw(s);
keeping all required records and depositing all monies into the designated lottery
trust account;
f)
2.2
2.3
2.4
The licensee may recruit sufficient persons
to assist with the sale of tickets.
vi.
The licensee must establish rules, consistent with these terms and conditions,
governing the conduct of the raffle and the
awarding of prizes. Rules must be made
available to ticket purchasers and must be
approved by the licensing authority.
the price of each ticke|
the number of the ticket, and;
vii. the total number of tickets
printed.
b)
On the part retained by the organization
(for draw or record purposes):
The licensee must not allow any person
who has had a registration under the
Gaming ControlAct, 1992 revoked or
refused to participate in any way in the conduct of the event.
3.1
3.3
v,
The licensee may use the services of a
person to assist in the conduct of the raffle
provided the person is registered under the
Gaming Control Act, 1992 and Regulations
or is otherwise exempt.
CONDUCT OFTHE EVENT
3.2
iv. a description, including the
nature, number and value of the prize(s)
to be awarded;
reconciling all tickets.
(3)
the name of the licensee;
i.
the number of the ticket;
¡¡. the licence number and the name
of the licensee;
¡¡¡. adequate space for the name,
address and telephone number of the
ticket purchaser.
4.4
lf tickets are to be discounted from the
regular price (for example, $1.00 or 3 for
$2.00), then the prices must be indicated
and printed on each ticket.
Once the first ticket is sold, the licensee
4.5
must complete the raffle and award the
prize(s) as approved in the application for
licence, whether or not all tickets have been
sold.
At the request of the licensing authority,
the licensee must provide a sample of the
ticket.
4.6
The licensee must not use any type of
"scratch and win" ticket.
4.7
Where prizes are donated, and the donor
and the licensee agree, the donor name
or company name may be included on
the ticket, provided that the name of the
licensee is more prominent.
4.8
Tickets must not bear any coupon, promotional or advertising material unless it is
promoting the licensee and approved by
the licensee.
(5)
TICKET SATES
5.1
The licensee must not allow any person
apparently under the age of 18 to purchase
a ticket.
Winner(s) must be determined in the
manner set out and approved in the application. For stub draws, only the sold ticket
stubs must be used for draw purposes.
(41
TICKET REOUIREMENTS
4.1
The licensee must print only the number of
tickets indicated and approved in the application for licence.
4.2
Tickets must be consecutively numbered.
4.3
a)
The licensee must have tickets printed
in two (2) parts which must contain the following information:
i.
60044E (2015/06)
the licence number;
Page 2 of 5
5.2
5.3
The licensee may accept cheques or credit
card payments and must be responsible for
ensuring that the proceeds from the ticket
sales are received. Any processing charges
for these types of payments must form part
of the expenses for the raffle.
l7l
ADVERTTSTNG
7.1
The licensee is responsible for the
design, placement and payment of any
advertisements.
7.2 a)
The licensee must ensure that
a)
raffle ticket orders are not solicited or
accepted from persons located outside of
Ontario;
tickets must both be physically present in
Ontario at the time the sale takes place;
c) the raffle lottery scheme is not advertised, promoted or otherwise marketed to
persons located outside of Ontario.
PRIZES
6.1
The winner(s) of the prize(s) must be determined and publicized in the manner set out
and approved in the application.
6.2
The licensee must be responsible for
awarding all prizes and for making all
reasonable efforts to contact the prize
winner(s).
6.3
6.4
6.5
Any prizes which are not claimed must
be secured or placed ín safekeeping for a
period of one (1) year from the date of the
draw. lf at that time the prize has still not
been claimed, the prize or monies equivalent to the fair market value of the prize
must be donated to a beneficiary approved
by the licensing authority.
the name of the licensee;
¡¡.
the licence number(s) issued;
iv. a description of the prizes to be
awarded, including their value;
v. the total number of tickets to be
printed and the price of the ticket.
b)
Radio and television advertisements
must provide, at a minimum, the name
of the licensee and the licence number(s)
issued.
7.3
The licensee must supply samples of
advertising and promotional materials
to be used in connection with the raffle
if requested to do so for approval by the
licensing authority.
7.4
The licensee must not engage in any advertising that:
a)
implies that participating in a lottery
event promotes or is necessary for social
acceptance, personal success, financial
success or the resolution of any economic,
social or personal problem;
Only the prize(s) as described and
approved in the licence application must
be awarded.
b) contains endorsements by well-known
personalities that may appeal to persons
under the 18 years of age; or
The value of the prize(s) must include the
amount of any duty, tax, sales tax or other
cost. Prize(s) must be awarded free and
clear of any mortgage, lien or any other
encumbrances.
c)
is specifically directed at encouraging
individuals under the age of 18 to participate in a lottery event.
7.5
6004A E (2015/06)
i.
i¡¡. the location, date and time at
which the draw is to be held, including the location, date and time of each
early bird draw and the cut-off time for
each early bird draw;
b) the vendor and purchaser of raffle
(6)
Print advertisements must clearly state:
Any advertising or promotional activities
by celebrities must be provided at no cost
to the licensee.
Page 3 of 5
{8)
PROCEEDS AND EXPENSES
8.1
The net proceeds derived from the conduct
of the raffle must be used for the charitable and religious objects or purposes in
Ontario as approved in the application for
licence.
8.2
All prizes and expenses incurred as a result
of conducting the raffle must be deducted
and paid out from the gross receipts
derived from the raffle.The licensee must
not use monies from any other source to
pay for raffle expenses.
8.3
The Registrar may limit the amount which
may be paid for expenses.
8.4
Expenses must be directly related to the
conduct of the raffle.
8.5
Each expense must be individually calcu-
9.5
The licensee must maintain books, records
and other documents in support of all
financial reports or statements. These
records must be kept up to date and be
retained for no less than four (4) years
from the date of the raffle.
9.6
The licensee must provide officers
appointed by the licensing authority and
all peace officers unencumbered access to
all books and records related to the conduct of the raffle and must deliver these
documents to the licensíng authority when
requested.The books and records may be
retained by the licensing authority for audit
and investigation purposes.
(10)
BANKING AND FINANCIAL
10.1
The licensee must open and maintain a
separate designated lottery trust account
to administer all funds related to the conduct of lottery events.The licensee has the
option of:
lated and paid separately by cheque, drawn
on the designated lottery trust account
described in Section 10.The licensee
must pay each Gaming-Related Supplier
separately.
a) opening and maintaining one desig-
a)
nated lottery trust account to administer all
lotteries conducted by the licensee; or
Ticket sellers may be paid a sales commission not to exceed five (5) per cent of
the price of each ticket sold.
b)
opening and maintaining separate designated lottery trust accounts for each type
of lottery conducted by the licensee.
b)
Sales commissions may be paid by
cash provided they are supported by a
receipt.
10.2
Each designated lottery trust account must
be maintained in the name of the licensee,
in trust, and must have the following
(e)
BOOKS AND RECORDS
featu res:
9.1
A serial number record must be maintained showing the distribution of tickets,
including the names of sellers, and the
return of ticket stubs, cash, unsold or
returned tickets to reconcile all tickets and
cash at the end of the raffle.
a)
9.2
The licensee must retain all unsold tickets,
and stubs or counterfoils of sold tickets for
a period of one (1) year from the date of
the (last) draw.
9.3
The licensee must obtain receipts for each
expense incurred.
9.4
The licensee must maintain a detailed
record of how profits from the raffle have
been dispersed.
60044 E (2015i06)
cheque writing privileges and monthly
statements issued;
b)
all cheques or electronic images of
backs and fronts of cheques returned with
monthly statement.
10.3
Any interest accrued on the lottery trust
account must be used for the charitable
purposes of the licensee.
10.4
ln administering the lottery trust account,
the licensee must:
a)
appoint a minimum of two (2) signing
officers, who must be bona fide members
of the licensee, to administer the account
and write cheques;
Page 4 of 5
b)
a)
deposit into the account all monies
derived from the operation of any and all
lottery events; monies must be deposited
as soon as it is practical to do so;
c)
copies of all deposit slips related to the
event;
b)
11.2
The financial report must be filed within
30 days of the date of the last draw.The
licensing authority may request additional
documents deemed necessary to substantiate the particulars of the event which may
ínclude receipts for each expense incurred.
11.3
The licensee must indicate any prizes
which have been donated on the financial
report.The value of the donated prizes
must not be deducted from the gross
receipts.
11.4
The licensee must provide the licensing authorities with a verified financial
statement on a yearly basis outlining the
financial details of all lottery events conducted.The financial statement must be
submitted within 180 days of the organization's year end.
11.5
b) transfer funds from the designated
The type of financial review required will
depend on the gross annual revenues
derived from all sources. A licensee that
receives:
lottery trust account into an operating or
general account of the licensee;
a)
ensure all withdrawals are made by
cheque;
d)
ensure cheques are written only for the
payment of the expenses incurred in the
conduct of the lottery and the donation of
net proceeds for the charitable purposes
approved on the application for licence.
10.5
The licensee must not:
a) i.
where only one designated
lottery trust account is maintained,
deposit monies received from any
source other than lottery events
conducted by the licensee into the designated trust account; or
¡¡. where a separate designated
trust account for raffle lotteries has
been established, deposit monies
received from any other source in the
designated raffle lottery account;
less than $250,000 in gross annual
revenues from all sources must prepare
financial statements in accordance with the
standards set out in the CICA Handbook
cl
close the designated lottery trust
account until all monies have been
donated to approved charitable purposes
and a report has been submitted to the
licensing authority.
10.6
a list of winners
Where only one designated lottery trust
account is maintained, the licensee must
maintain separate ledgers outlining financial details of each lottery event conducted
including proceeds derived from each,
expenses paid in the conduct of each lottery event, and a list of how proceeds have
been dispersed.
(11 )
REPORTING REOUIREMENTS
11.1
The licensee must provide the licensing
authority with a financial report outlining
the results of the raffle on the prescribed
form.The following documents must
accompany the financial report:
6004AE (201sl06)
b)
$250,000 or more in gross annual
revenues from all sources must prepare
financial statements in accordance with the
standards set out in the CICA Handbook
which have been audited by a public
accou nta nt.
11,6
Where requested, the licensee must provide an audited financial statement to the
licensing authority within 120 days of the
request or such other time limit as may be
imposed by the licensing authority.
11.7
The licensee may use lottery proceeds
to pay for expenses related to the preparation of the yearly financial statements.
This expense must not be included in any
expense maximum within the terms and
conditions.
Page 5 of 5
rö
Alcohol and
Gaming
Comm¡ssion des alcools
Group Identif¡cation Number (GlN)
Numéro d'ident¡ficat¡on d'organ¡sme (NlO)
Ontario et des jeux de l'Ontar¡o
Registration and lnsc¡ipt¡on pour ¡es jeux
Comm¡ss¡on of
Gaming
Lotter¡es
el loteries
ShepFrd Ave. E., Sullo 200
Torcnto ON M2N0A4
S0, av. Shsppad Esl, bureau 2m
Toronto ON M2N0A4
90
Application to Manage ând
Conduct a Raffle Lottery
Demande de permis pour adm¡nistrer
et conduire une tombola (tirage)
416-326-a700 1-800-522-2876 lôll fÍee in Onlãrio / sâns iiâ¡s eô Ônlâilô
We, the unders¡gned, as two principal officers
Les soussignés, qui sont deux principaux dirigeants de
(organisme)
fecord
Address
Adresse
apply for a licence to manage and conduct a Raffle Lottery from the
premìses municipally known as
font une demande de permis pour adm¡nistrer et conduire une
tombola(tirage) dans les locaux connus dans la mun¡cipalité sous
le nom de
and situated in the Municipality of
et situés dans la munic¡palité de
between the dates spec¡fied, and for the charitable or religious objecls
and purpÕses, and in the manner described herein.
'L The Charitable or religious objects or purposes to which proceeds
are to be donated are described as
enlre les dates indiquées, à l'¡nlention des oeuvres religieuses ou de
b¡enfaisance spécifiées et de la manière décrite dans les présentes.
Les profits seront réparl¡s aux oeuvres religieuses ou de
bienfaisance suivantes.
2. The total value of all prizes to be awarded
¡n the Raffle Lottery Tor
which lhis application is made will be $...................................cash
value, or merchandise or articles at equivalent market retail value.
Merchandise prizes are described as
2.
La valeur totale de tous les prix qui seront attribués dans le cadre
de ¡a tombola (tirage) pour laquelle cette demande est faite sera
de................................ $ en espèces, ou une valeur équivalente
au détall.
Les prix de valeur au détail consisteront en
3.
Closing date for the sale of the tickets will be .................................
and the draw for a winner or winners will be made al (address)
3.
Ladatefinale pourlavenlede billetsserale.........
on (date)............................................
et le tiragê du ou des gagnant(s) sera fait au (adresse)
at (time)....
lf a series of draws, beginning date...
ending date.................,....,............. Number of draws ..........
4. A winner or wìnners will be determined by (describe)
et le nom et l'adresse du ou des gagnant(s) seront connus par
(précise0
and the name(s) and address(es) of the winner or winners will be
published (describe)
5.
5. Thetotal numberof ticketstobeprintedwill be..................................
+^
Le nombre total des billets qu¡ seront ìmprimés sera de......,......
et tous les billets portêront des numéros consécutifs allant de
and all tickets will be numbered consecut¡vely from...
Dr¡^ô
.
à........................Prixdu bi||et............
Certificate / Attestâtion
We (name)/Nous soussignés(nom)
of (organization) /de organisme).......
of
(municipality)/de(municipalité)...
of
the countyof/ducomtéde..........
jo¡ntly and severally, hereby certify thaíattestons collectivement et individuellement que:
1
and have ¡n our possession, and âgree to comply
with, the provisions of Schedule A-Terms and Cond¡tions under
wh¡ch the Lottery Licence ¡s ¡ssued.
We have read over th¡s applicat¡on.
All facls stated and ¡nformalion furnished herein are true and
correct.
We are the holders of the offíces with descriplive title as set out
and appearing under our respective signatures below.
lf a licence is granted, we undertake to comply with all the terms
and conditions of such licence.
) We have read,
2)
3)
4)
5)
Signed/Signature
Pr¡nt Name/Nom en
lettres moulées
Title/Titre
Bus. Telephone No.
N". de té|. d'aff.
Date/Date
Witness (sign)
Témoin(signature)
6004 B (06/0s)
1) Nous avons lu les dispositions de I'annexe A- moda¡ités inhérentes
à la délivrance d'un permis de tombola (firage), que nous les avons
en notre possession et que nous acceptons de nous y conformer,
¿l Nous avons lu la présente formule,
3) Tous les laits indiqués et les renseignements fourn¡s dans les
présentes sont véridiques et exacts,
4) Nous assumons les fonctions correspondant aux titres spécifiés
sous nos signatures respectives ci-dessous,
5) Si un permis est délivré, nous engageons à en observer les
modalités.
@
Ontario
Gaming
Ontario
Gaming Registration and Lotteries
90 Sheppard Avenue East
Suite 200
ïoronto ON M2N 044
Alcohol and
Gommission of
Commission des alcools
et des jeux de l'Ontario
Lottery ReporURapport de loterie
Group ldentification Number (GlN)
Numéro d'identification d'organisme (N.l.O.)
lnscription pour les jeux et loteries
90, avenue Sheppard Est
Bureau 200
Toronto ON M2N 044
(416) 326-8700 1800 522-2876 toll free ¡n Ontario/sans frais en Ontario
Note: This report must be filed with the Lottery Licensing Officer within 30 days of the holding of the lottery in accordance with the terms and conditions under
which the lottery licence was issued.
Remarque : ll faut soumettre ce rapport à I'agent(e) de délivrance des licences de loterie dans les trente jours qui suivent la loterie conformément aux modalités
en vertu desquelles la licence de loterie a été délivrée.
1. Organization Name - Address/Nom et adresse de l'organisme
Lottery Licence No./N" de licence de loterie
Type of Lottery/Genre de loterie
Raffle/Tombola
BazaarlV enle de charité
(tirage)
Lottery Date/Date de la loterie
2. Total number of tickets or cards / Nombre total de billets ou de cartes
Printed/lmprimés
SoldA/endus
Price per TickeVPrix du billet
Unsold/Non vendus
Note: ln the case of a Raffle, a list of all prize winners must accompany the return of this report.
Remarque : S'il s'agit d'une tombola (tirage), la liste des gagnants des prix doit accompagner le présent rapport.
3. Total Gross Receipts derived from lottery/Total des recettes brutes tirées de la loterie
................ $
Application of Funds/Affectation des fonds
(a) Total value of prizes awardedfualeur totale des prix attribués
(b)
Total administrative costs incurredÆotal des frais d'administration
engagés (attach itemized lisUjoindre une liste détaillée)
-$
...... -$
Net proceeds derived/Recettes nettes obtenues
4. Details of
Name of
sur les dons
du bénéficiaire
................ $
or
actual donated/Recettes réellement
Amount Donated/Montant donné
Address of Payee/Adresse du bénéficiaire
Total value of proceeds actually donated for charitable or religious purposes/
Valeur totale des profits réellement donnés à des oeuvres religieuses ou de bienfaisance
$
5. Chartered Bank, Loan or trust company or Province of Ontario Savings Office in which the Lottery Trust Account is kepUBanque
à
charte, compagnie de prêt ou de fiducie ou caisse d'épargne de la province de l'Ontario où se trouve le compte de loterie en fiducie
Name of Bank/Nom du la banque
Branch Address/Adresse de la succursale
Balance of proceeds retained in Lottery Trust AccounUSolde des profits conservé
dans le compte de loterie en fiducie
Account Number/Numéro de compte
$
We, the undersigned, as two Principal Officers of the above organization, certifythatthe above report is a correct statementof the lotteryfunds herein.
Nous, soussignés, à titre de d¡rigeants pr¡ncipaux de I'organisme mentionné ci-dessus, attestons que le rapport qui précède décrit correctement l'état des
fonds de loterie en
Principal Officer/Dirigeant principal
Signature
Name in full/Nom au complet
Title/Titre
Bus. Telephone/Téléphone d'aff,
Date
06347 B (06/05)