Fillable Application for a Permit to Conduct a Raffle (Town of Wethersfield)

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Application for a Permit to Conduct a Raffle (Town of Wethersfield)

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Application for a Permit to Conduct a Raffle
Instructions:
1. The completed form shall be submitted to:
at least fifteen (15) days prior to the start of the raffle.
2. This application must include a sample draft of the raffle ticket.
3. Applying organization must be a qualifying non-profit functioning for a minimum of six (6) months.
4.
Your application must be completed, signed, and accompanied by a check or money order made payable to:
Name of Sponsoring Organization
If this organization previously held a raffle permit, list permit number:
FEIN
IRS Exempt Status Code
Street Address
City
State
Zip Code
Mailing Address (if different than above)
City
State
Zip Code
Telephone Number (with area code)
Contact Person for this Application
Contact Telephone Number
Contact Email Address
Organization Category (check only one):
An educational or charitable organization
An officially recognized organization or association of
veterans of any war in which the U. S. was engaged
A civic, service, or social club An officially recognized volunteer fire company
A fraternal or fraternal benefit society
A political party or town committee of the municipality in
which the raffle is to be held
A church or religious organization
Give the names of the three (3) Designated Active Members of the sponsoring organization under whom the raffle
is to be conducted. These individuals will affix their signature to the statement form. The three (3) Designated
Active Members must be residents of the state of Connecticut.
First Name
Last Name
Telephone Number (with area code)
Date of Birth
First Name
Last Name
Telephone Number (with area code)
Date of Birth
First Name
Last Name
Telephone Number (with area code)
Date of Birth
Ranking Officer Name
Title
Date of Birth
Residence Street Address
City
State
Zip Code
For Official Use Only
St. John's Church - Mens Club
RAFF.9999.CL5
06-1122334
501 (C) 3
263 Cedar Mountain Rd
Anytown
CT
06000
PO BOX 1
Anytown
CT
06000
(860) 555-5309
stjohnsmen@gmail.com
William Couto
(860) 555-5555
wcouto@gmail.com
William
Couto
(860) 555-5555
07/16/1942
Trevor
Smith
(860) 555-7236
08/27/1967
Edward
McDonald
(860) 555-6391
03/04/1953
William Couto
President
07/16/1942
263 Pumpkin Delight
Anytown
CT
06000
SAMPLE
Starting Date of Sales
Drawing Date
Time of Drawing
AM
PM
Number of Tickets to be Printed
Unit Price of Tickets to be Sold (only one price)
Place Where Drawing is to be Held:
Name of Place
Street Address
City
State
Zip Code
List the items of expense intended to be incurred or paid in connection with the holding, operating, and conducting
of such raffle and the names and addresses of the persons to whom, and the purposes for which, they are to be paid.
*Attach additional sheets as necessary.
Expense ($)
Name
Street Address
City
State
Purpose
Separately list in detail all items offered as prizes in connection with such raffle, indicate whether or not the items
were donated, list the price to be paid by the organization or the retail value of any prize donated, and the names
and addresses of persons from whom the items were purchased or by whom donated.
*Attach additional sheets as necessary.
Merchandise
Donated
Yes/No
Retail
Value
Amt. Paid
by Org.
Name
Street Address
City
State
State the specific purpose to which the entire net proceeds of such raffle are to be devoted.
I certify, under penalty of law (Sec. 53a-157b, Class A Misdemeanor), that the information provided on this
application is the truth to the best of my knowledge.
Signature of Ranking Officer
Date
Raffle Classification:
Class I $ .00
∙Max. aggregate prize
total of $15,000
∙Max. time 3 months
∙Allowed 1 per year
Class II $ .00
∙Max. aggregate prize
total of $2,000
∙Max. time 2 months
∙Allowed 3 per year
Class IV $ .00
∙Max. aggregate prize
total of $100
∙Max. time 1 month
∙Allowed 1 per year
Class V $ .00
∙Max. aggregate prize
total of $50,000
∙Max. time 9 months
∙Allowed 5 per year
Class VI $ .00
∙Max. aggregate prize
total of $100,000
∙Max. time 12 months
∙Allowed 5 per year
Raffle Description: (Check Only One)
Winner Need Not Be Present Duck Race
Cow Chip Frog Race
Winner Must Be Present
(must be on ticket)
Cash Prize
(dedicated bank account info required)
Bank Name
Dedicated Account Number
Special Tuition
(dedicated bank account info required)
Bank Name
Dedicated Account Number
January 25, 2015
May 25, 2015
06:00
10,000
$5.00
St. John's Church Hall
263 Cedar Mountain Rd
Anytown
CT
06000
$40.00
Town of Anytown
105 Cedar St.
Anytown
CT
Permit Fee
$250.00
Quick Printing Shop
93 Tremont St
Anywhere
CT
Raffle ticket printing
$1,500.00
Scenic Travel Agency
1 Reynolds Ln
Anywhere
CT
Trip to Florida
$32,000.00
Larry's Cadillac
95 Curtiss St
Anywhere
CT
Raffle prize
2014 Cadillac CTS
no
$32,000.00
$ 32,000.00
Larry's Cadillac
95 Curtiss St
Anywhere
CT
Trip to Florida
no
$1,500.00
$ 0.00
Scenic Travel Agency
1 Reynolds Ln
Anywhere
CT
Kenwood CD player
yes
$239.99
$ 0.00
The Music Shop
1125 Park Ave
Next-Town
CT
At&t cordless phone
yes
$127.00
$ 0.00
Bill's Phone & Appliance
12 Franklin Ave
Next-Town
CT
To Help balance the budget for St. John's Catholic school
10/15/2014
William Couto
STATEMENT OF ACTIVE MEMBERS DESIGNATED BY SPONSORING
ORGANIZATION UNDER WHOM THE RAFFLE IS TO BE HELD, OPERATED OR
CONDUCTED
We, the undersigned, do hereby EACH make the following statement under the penalty of False Statement with
respect to the foregoing application:
1. I am a resident of the state of Connecticut.
2. I am a bona fide active member of the sponsoring organization making this application to conduct a raffle and
all statements contained in this application are true to the best of my knowledge and belief.
3.
I will be re
sponsible for the holding, operation and conduct of such raffle in accordance with the terms of the
permit, the provisions of the Act, and regulations.
4. I have never been convicted of a felony.
5. I am familiar with the provisions of the Act which PROHIBIT:
a.
The giving of cash prizes, except with an approved “Class No. 1”, “Class No. 2”, “Class No. 4”, cow-chip,
duck-race, golf ball drop (“Class No. 6” only), or frog-race raffle permit.
b. The giving of alcoholic beverages as prizes.
c. The giving of prizes redeemable for cash.
d. The paying of commission, salary, compensation, reward or recompense, directly or indirectly, to any
person holding, operating, conducting or assisting therein in the operation of a raffle.
e. The promotion or operation of a raffle by other than duly qualified members of the sponsoring
organization.
f. The giving of pay to any member for his time or effort in connection with a raffle.
g. The promotion, conduct or operation of a raffle by a person under the age of 18 or the permitting of same
by the sponsoring organization.
h. The selling or promoting of the sale of raffle tickets by persons under the age of 16 years, or the
permitting of the same by the sponsoring organization.
i. The use of funds derived from the raffle for purposes other than as stated in this application.
j. The paying of any monies except in reasonable amounts for goods, wares and merchandise furnished or
services rendered which are necessary for the operation of a raffle.
6. I am familiar with the provisions of the Act which:
a. Provide that each raffle ticket shall have printed thereon the time, date and place of the raffle, the three
most valuable prizes to be awarded and the total number of prizes to be awarded.
b. Require all proceeds from cash prize raffles to be deposited in a special checking account established and
maintained by the sponsoring organization, and all raffle expenses and cash prizes awarded shall be paid
from such account.
c.
Require all procee
ds from special tuition raffles to be deposited in an approved dedicated bank account
and all raffle expenses shall be paid from such account.
d. Make mandatory the immediate revocation of a permit to conduct a raffle for a violation of the provisions
of the Bazaar or Raffle Act, and which provide that an organization whose permit has been revoked for a
violation shall not be granted another permit for a period of three years.
e. Provide a fine of not more than one thousand dollars or imprisonment for not more than one year or both
for a violation of the Act.
PRINTED NAMES AND SIGNATURES OF DESIGNATED ACTIVE MEMBERS:
NAME (Please print)
1.
NAME (Please print)
2.
NAME (Please print)
3.
SIGNATURE AND DATE
SIGNATURE AND DATE
SIGNATURE AND DATE
For Official Use Only
SAMPLE
Trevor Smith
William Couto
Edward McDonald
Trevor Smith
10/15/2014
William Couto
10/15/2014
Edward McDonald
10/15/2014
ST. JOHN’S CHURCH
MEN’S CLUB
NAME
ADDRESS
TOWN
STATE ZIP
PHONE ( )
No. 00000
RAFFLE
Sponsored by
ST. JOHN’S CHURCH - MEN’S CLUB
To benefit
St. John’s Catholic School’s Budget
SIX (6) PRIZES TO BE AWARDED
1
ST
PRIZE: 2015 Cadillac CTS
Air conditioning, power locks and windows, cruise control, and
AM/FM stereo with CD player
2
nd
PRIZE: Trip for 2 to Orlando, Florida. Includes 6 days/5 nights hotel
accommodations and round trip airfare (value $1,500.00)
3
rd
PRIZE: 50” flat screen TV
4
th
PRIZE: Apple iPhone
5
th
PRIZE: $50.00 gift certificate redeemable at Taylor’s Food Mart,
Market Plaza, 5 Market Road, Anytown, CT
6
th
PRIZE: 2 tickets to a performance of Madame Butterfly redeemable at the Winter
Garden Theater
DRAWING TO BE HELD: May 25, 2015 at 11:00 p.m.
St. John’s Church Hall
263 Cedar Mountain Road
Anytown, CT 06000
Ticket holders need not be present to win
PRIZES NOT REDEEMABLE FOR CASH AND EXCLUDE ALCOHOLIC BEVERAGES
No. 0000
0 Price: $5.00
Page 1 of 5
Sample Raffle Application Instructions
INSTRUCTIONS TO COMPLETE A RAFFLE APPLICATION
Please complete each section on the Application for a Permit to Conduct a Raffle form, the Statement of
Active Members form, and provide a sample raffle ticket. A step-by-step set of instructions is listed below in
order to ensure proper completion of the forms.
APPLICATION FOR A PERMIT TO CONDUCT A RAFFLE
1. If the organization has a determination letter from the IRS confirming the organization’s exempt
status, please include a copy.
2. Provide a complete name and address (number, street, city/town, state, zip) of the sponsoring
organization.
3. Provide a complete mailing address (number, street, city/town, state, zip) of the sponsoring organization.
4. Provide a telephone number and email address.
5. Provide the name, telephone number, and email address of the contact person for this application.
6. Choose one of the seven (7) categories that applies to your organization.
7. Give the complete name, telephone number, and date of birth (month, day, year) for each of the three
Designated Active Members
Note: The three Designated Active Members MUST be residents of the State of
Connecticut and at least eighteen years of age.
8. Provide the complete name (first, middle, last), title, complete date of birth (month, day, year), and
complete home address (number, street, city/town, state, zip) for the officer of the sponsoring
organization.
9. Choose the raffle classification for this application.
10. Choose the description that best describes this raffle (only choose one).
11. Complete bank information if applicable.
12. Provide the starting date and the terminating date (month, day, and year) of the raffle, along with the
time (including a.m. or p.m.) for the raffle drawing.
13. Provide the number of tickets to be printed and the uniform price (ie: no discounting for volume).
14. Provide a complete address (name of place, number, street, city/town, state, zip) of the place where the
raffle drawing is to be held.
15. Provide all of the expenses directly incurred for the raffle activity including permit fees and ticket
printing etc. and the names and addresses to whom they were paid.
Page 2 of 5
Sample Raffle Application Instructions
16. Provide all the merchandise information that will be awarded for the raffle activity including the
names and addresses of the persons/organizations from whom the items were purchased or donated.
Note: If an item is donated then the “Retail Value” must be completed.
If the item is purchased then the “Amt. Paid by Org.” must be completed.
If an item is purchased at a reduced price, complete the “Amt. Paid by Org.”
17. Provide the specific purpose of the entire net proceeds.
18. The ranking officer of the sponsoring organization must sign his/her name, provide his/her title, and
date the form.
Note: Only the individual listed on the front of this application is recognized as an
officer and may sign as the ranking officer.
STATEMENT OF ACTIVE MEMBERS
The three Designated Active Members listed on the application must
read the information provided on the
Statement of Active Members form, print their names in the designated areas and affix their signatures to the form.
ALLOWABLE RAFFLE PRIZES
All prizes given at any raffle shall be merchandise, tangible personal property or a ticket, coupon or gift
certificate, entitling the winner to merchandise, tangible personal property, services, transportation on a
common carrier by land, water or air and to any tour facilities provided in connection therewith, or to
participation in a lottery conducted under Chapter 226. Such ticket, coupon or gift certificate shall not be
refundable or transferable. No cash prizes or prizes consisting of alcoholic liquor shall be given, except as
provided in Section 5 of the Bazaar and Raffle Act, and no prize shall be redeemed or redeemable for cash,
except tickets for a lottery conducted under Chapter 226. Coins whose trading value exceeds their face value
and coins not commonly in circulation shall not be deemed a cash prize. Section 5 of the Act provides that a
sponsoring organization with a “Class No. 1”, “Class No. 2” or “Class No. 4” traditional, cow-chip, duck-
race, golf ball drop, or frog-race raffle permit may award cash prizes in addition to the aforementioned prizes.
EACH TICKET MUST HAVE PRINTED THEREON:
- The name of the sponsoring organization.
- The date (month, day, year), time (including a.m. or p.m.), and place (number, street, city/town, state) of
the drawing.
- The price of the ticket.
- At least the three most valuable prizes to be awarded.
- The total number of prizes to be awarded.
- Each ticket must be numbered and must have a correspondingly numbered stub or counterpart with a
designated space for the name and address of the ticket holder.
Note: A sample of the raffle ticket must be attached for approval. A printer’s proof or a legible specimen ticket
may be provided. UNDER NO CIRCUMSTANCES may an organization print tickets prior to
receiving a raffle permit, which may only be issued by the appropriate municipal official.
Page 3 of 5
Sample Raffle Application Instructions
HELPFUL REMINDERS
The name of the sponsoring organization must appear exactly the same as the name that has been printed on the
application form. It must be apparent to the purchaser of a ticket which organization is “sponsoring” the raffle.
The drawing information, such as the date, time and place of the drawing, should appear in one general area on
the ticket.
The unit price of the raffle ticket must be printed on the ticket. Please note that all tickets shall be sold at a
uniform unit price for each ticket without any discount or allowance for the purchase of more than one ticket.
The three most valuable pr
izes to be awarded must be printed on the raffle ticket. An organization may,
however, list all prizes to be awarded if it desires to do so.
The total number of prizes to be awarded must be printed on the ticket (even if only one prize is to be awarded).
The organization must label each prize (example: 1
st
prize, 2
nd
prize, etc.) regardless of the number of prizes to
be awarded.
The sample ticket must be numbered and must have a correspondingly numbered stub or counterpart with a
designated space for the name and address of the ticket holder. An organization may indicate on the sample
ticket where each ticket will be numbered by using one of the following:
# # XXXX
00 TICKET NO.
If the presence of the winner is required at the raffle drawing, this statement must be printed on the raffle
ticket.
ACCEPTABLE WORDING OF PRIZES PRINTED ON A RAFFLE TICKET MERCHANDISE PRIZES:
(example: lamp, cordless phone, dvd player, etc.)
- Merchandise prizes should be listed with a description of the item.
- The name of the place or business where the prize was obtained may not be listed on the ticket, since it would
be considered advertising matter, which is prohibited (unless it is a gift certificate redeemable at that specific
location). This information may be placed on any other material an organization may distribute such as
pamphlets, flyers or posters, but it may not appear on a raffle ticket.
- The value may be listed after the description of the item of merchandise, but is not required to be printed on
the ticket.
* May Word As: 20” Color TV With Remote Control
Floral Wreath (Value $50.00)
Page 4
of 5
Sample Raffle Application Instructions
- The choice of merchandise prizes is allowed, provided that the choice is limited to not more than one of two
specific items of merchandise of equal value, and a complete description of each item must be printed on
the raffle ticket.
- The choice of a prize is strictly limited to merchandise items, and is not allowed for any other type of
prize that may be offered in a raffle.
* May Word As: Crystal Bowl OR Crystal Vase
GIFT CERTIFICATES:
- Gift certificates entitle the holder to exercise his/her option in the choice of an article of merchandise. Gift
certificates that are redeemable at restaurants, grocery stores, malls, etc. where alcoholic beverages may
be obtained must bear a notation, which states that the gift certificates may not be redeemed for alcoholic
beverages. In offering a gift certificate as a prize, an organization cannot describe what the holder will
receive when they redeem the gift certificate at a particular establishment. In other words, if an organization
wants to award a specific item of merchandise, it cannot offer a gift certificate as the prize. In such a
situation, it should simply offer the item it desires to award rather than the gift certificate.
* May Word As: $200.00 gift certificate redeemable at Sam’s Music Center
$50.00 gift certificate redeemable at Lucian’s
Restaurant (EXCLUDES ALCOHOLIC BEVERAGES)
SERVICES: (example: haircut, manicure, oil change, etc.)
- When a service is offered as a prize, it must be awarded as a gift certificate. This is to prevent organizations
from giving the winners cash in order to pay for the service. However, since the original intent was to award
a particular service to the winner, the organization may describe the kind of service(s) the winner will
receive. If the service to be awarded must be completed within a certain period of time (example: 1 hour) or
is limited to a certain number of people or objects, that information must be provided as part of the prize
description.
* May Word As: $25.00 gift certificate for haircutting services for 1 person redeemable
at Sue’s Beauty Salon
$100.00 gift certificate for oil change and tune-up services for one vehicle
redeemable at Ron’s Auto Service Center
$75.00 gift certificate for two hours of house cleaning services for
one home redeemable at Neat and Clean
- This is the only exception allowed in the awarding of gift certificates. All other gift certificates must be
worded as previously mentioned.
CHOICE OF MERCHANDISE PRIZES:
Page 5 of 5
Sample Raffle Application Instructions
AIRLINE TICKETS:
- Must be treated in the same manner as a gift certificate by using the words “redeemable at”.
- Must also state if the tickets are roundtrip or one-way.
- Tickets must be to a specific destination.
* May Word As: 2 roundtrip airline tickets to Orlando, Florida redeemable at Cougar
Airlines
MEMBERSHIPS: (example: health club)
- Must be treated in the same manner as a gift certificate by using the words “redeemable at”.
- Must also state length of membership and the number of members involved.
* May Word As: 1 Year Membership for one person redeemable at Best Fitness Center
GAME OR SHOW TICKETS: (example: sports games, plays or theater)
- Must be treated in the same manner as a gift certificate by using the words “redeemable at”.
- May also list the date of the game or performance.
* May Word As: 4 tickets to the New York Yankees vs. Boston Red Sox game on 9/06/14
redeemable at Yankee Stadium
2 tickets for the performance of Madame Butterfly redeemable at the
Winter Garden Theater
TRIPS/PACKAGE DEALS: (example: trips including airfare, accommodations, etc.)
- The organization must provide a complete destination, the number of people the prize will accommodate, the
length of time involved, and specify what is included in the package such as accommodations, airfare, meals,
etc.
- Must print the words "Excludes Alcoholic Beverages” in parentheses directly after the description of the
prize, or the words “Prizes Exclude Alcoholic Beverages” somewhere on the body of the ticket, whenever
alcohol may inadvertently be obtained with a prize, such as with meals.
* May Word As: Trip for 2 to Long Beach, California, includes roundtrip airfare,
7 days/6 nights’ accommodations at the Sunrise Hotel, and dinner
each evening
LOTTERY TICKETS:
- Must print a specific description of the amount and type of Connecticut State Lottery tickets to be awarded as
a prize.
* May Word As: 25 Connecticut Instant Lottery Tickets
5 Connecticut Advanced Action Lotto Tickets
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Application for a Permit to Conduct a Raffle (Town of Wethersfield)

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Completed 17 July 2020

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