RM OF SHELL RIVER

CERTIFICATE

 We, (Name) ___________________________________ and (Name) _______________________________________ of (Organization) __________________________________________________ of the ___________________________, jointly and severally, hereby certify that:

1)                 We have knowledge of the matter herein set out.

2)                 We have read over this application.

3)                 All facts stated and information furnished herein are true and correct.

4)                 We are the holders of the offices with descriptive titles as set out and appearing under our respective signatures below.

5)                 If a license is granted, we undertake to comply with the terms and         conditions of such license.

Signed _____________________      Signed __________________________

 Print Name _________________        Print Name_______________________

Title_______________________         Title____________________________

Address_______________________   Address_________________________

Date________________________        Date___________________________  

Witness (sign)__________________     Witness (sign)____________________



(Issued under the authority of the Department of Attorney-General)

Province of Manitoba

Licence No. _________

Council of the Rural Municipality of Shell River of Roblin , Manitoba .

 LICENCE

 _____________________________________________________________

is licensed to manage and conduct a ___________________ Lottery Scheme at

or from the premises municipally known as _____________________________

1.         and situated in the Municipality of Shell River subject to all the terms and             conditions as agreed by the Licensee in its application, and upon the date                or during the period and within the hours and to the limits set out herein.

(1)       Date of Period           ______________________________

(2)       Frequency ______________________________________

(3)       Hours (From) _____________________  (To) _____________________

(4)               Total value of all prizes in any lottery conducted under this license not to exceed  $_____________ in cash, or merchandise or articles at equivalent market value.

Date Issued ____________, 20__         License Fee $_______________

___________________________

Authorized Signing Officer

(non-transferable)

R.M. OF SHELL RIVER

RAFFLE FINANCIAL STATEMENT

(Issued under the authority of the provincial auditor, Province of Manitoba )

Name of Licencee: _______________________________________________

Licence Number: _____________            Date Licence Issued: _______________

Date of Period of Lottery: ______________________

Statement showing accounting for funds

             Gross Receipts:   __________

Administrative Expenses:

            Printing Tickets         _________

            Advertising                 _________

            Other                           _________

            Cost of Prizes            _________

            Total Expenses:        __________

Net Receipts:                         __________

Clearly identify how the net receipts have or will be distributed and for what purpose:

             Purpose                                             Amount

            ___________________                 ______

            ___________________                 ______

            Total Distribution:                              __________

             Total Number of Tickets Printed:      __________

            Number of Unsold Tickets on Hand   __________

            Number of Tickets Sold                      __________

            No. of Tickets Not Accounted For     __________

 I certify that the foregoing is a true and correct statement accounting for the funds of the lottery scheme licenced by the R.M. of Shell River under Licence Number ____________.

________________________                            _____________________
(Witness)                                                                        (Licencee Treasurer)       

 Dated at _______________ this _______ day of ______________ 20____

APPLICATION FOR LICENSE TO MANAGE AND CONDUCT A RAFFLE LOTTERY

Name of Organization: ______________________________________________

Address of Organization: ____________________________________________

Closing date for the sale of tickets will be _____________, 20___ and the draw will be made at _____________________ on _______________, 20___.

                                         (location)  

Price of Tickets: ____________________ No. of tickets to be printed: _________

Name of the Printer: ________________________________________________

Retail value of all prizes to be awarded: ________________________________

Actual cost of all prizes to be awarded: _________________________________

How will your organization guarantees payment of the prizes?

_______________________________________________________________

  Describe how tickets will be drawn and in what order:

________________________________________________________________

________________________________________________________________

________________________________________________________________

Clearly identify the charitable purposes for which the proceeds of this lottery will be used:

________________________________________________________________

________________________________________________________________

List Current Executive of Your Organization

                        Name                                      Address                    Telephone

President ___________________________________________________

Vice President _______________________________________________

Secretary Treasurer ____________________________________________

Raffle Chairperson _____________________________________________

Raffle Committee________________________________________________