Application for a Permit to Conduct a Raffle
Instructions:
1. The completed form shall be submitted to:0HULGHQ3ROLFH'HSDUWPHQW5HFRUGV:HVW0DLQ6W0HULGHQ&7
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
City of Meriden" Fee schedule is on page 2 of this application.
Name of Sponsoring Organization
If this organization previously held a raffle permit, list permit number:
Federal ID Number
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)
Email Address
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 (mm/dd/yyyy)
First Name
Last Name
Telephone Number (with area code)
Date of Birth (mm/dd/yyyy)
First Name
Last Name
Telephone Number (with area code)
Date of Birth (mm/dd/yyyy)
Ranking Officer Name
Title
Date of Birth (mm/dd/yyyy)
Residence Street Address
City
State
Zip Code
MPD Rev. 12/17
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 $75.00
Max. aggregate prize
total of $15,000
Max. time 3 months
Allowed 1 per year
Class II $30.00
Max. aggregate prize
total of $2,000
Max. time 2 months
Allowed 3 per year
Class IV $ 15.00
Max. aggregate prize
total of $100
Max. time 1 month
Allowed 1 per year
Class V $120.00
Max. aggregate prize
total of $50,000
Max. time 9 months
Allowed 5 per year
Class VI $150.00
Max. aggregate prize
total of $100,000
Max. time 12 months
Allowed 5 per year
Raffle Description:
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
MPD Rev. 12/17
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 responsible for the holding, operation and conduct of such raffle in accordance with the terms of the
permit, the provisions of the A
ct, 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 proceeds from special tuition raffles to be deposited in an approved dedicated bank account
and all raffle expenses s
hall 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
MPD Rev. 12/17
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