§ 111.095 RAFFLE REGISTRATION FORM.

City of Belleville Raffle License Application

(Please submit application with the $5 fee to the City Clerk)

Organization Name: _________________________________________________________________________________

Address: __________________________________________________________________________________________

Phone: ___________________________________ E-Mail: _________________________________

Type of Organization (check one):

___________________ Religious   ___________________ Charitable   ___________________ Labor

___________________ Veterans    ___________________ Fraternal    ___________________ Educational

___________________ Non-Profit Business

How long has this Organization been in existence? _______________________________________________________

Place/Date of Incorporation: ___________________/___________________

(Attach Certificate of Good Standing and Articles of Incorporation.)

Date(s) of Raffle Ticket Sales: ___________________ to ___________________ (Maximum of 90 days)

Location(s) of Ticket Sales: __________________________________________________________________________

Location for Determining Winners: ___________________________________________________________________

Manner for Determining Winners: ___________________________________________________________________

Date(s) for Determining Winners: ___________________________________________________________________

Total Retail Value of All Prizes Awarded: $___________________________________________________________ (Maximum of $25,000)

Maximum Retail Value of Each Prize Awarded: $______________________________________________________ (Maximum of $15,000)

Maximum Price Charged for Each Chance Sold: $______________________________________________________ (Maximum of $25)

FOR CITY CLERK’S OFFICE USE ONLY

______________ Approved   ______________ Denied   Date: ________________    License # ________________

Organization Raffle Manager Name: _________________________________________________________________

Address: ________________________________________________________________________________________

Phone: ________________________________      E-Mail: __________________________________

Raffle Manager Bond (check one):

A fidelity bond in favor of the Organization, in the amount of $1,000 must be submitted with this Application.

or

This bond is waived because the members of the Organization have requested the waiver of the fidelity bond by unanimous vote.

The undersigned hereby certify and attest as follows:

•   The information contained in this Application is true and correct;

•   The entire net proceeds of the Raffle will be exclusively devoted to the lawful purposes of the Organization;

•   No person except a bona fide member of the sponsoring organization will participate in the management or operation of the Raffle;

•   No person will receive any payment or profit for participating in the management of the Raffle;

•   The Organization will only rent a premises on which to determine the winning chance or chances in a raffle from another organization which is also licensed to have raffles;

•   The Organization shall keep records of its gross receipts, expenses and net proceeds for each single occasion at which winning chances are determined, and all deductions from gross receipts for each single occasion shall be documented with receipts or other records indicating the amount, a description of the purchased item or service or other reason for the deduction;

•   The distribution of net proceeds shall be itemized as to payee, purpose, amount and date of payment;

•   The Organization shall have separate records of each raffle conducted, and the person who accounts for gross receipts, expenses and net proceeds from the operation of raffles on behalf of the Organization shall not be the same person who accounts for other revenues of the Organization;

•   The Organization licensed to conduct raffles shall report monthly to its membership, and to the City, its gross receipts, expenses and net proceeds from raffles, and the distribution of the net proceeds itemized, and such report shall be submitted to the City Clerk’s office on the first of each month;

•   The officers, operators, manager and workers of the Organization and the Raffle have not been convicted of a felony, are not professional gamblers or gambling promoters, are of good moral character;

•   The aforementioned Raffle Manager shall be responsible for the conduct of the Raffle in accordance with Chapter 111of the Revised Code of Ordinances and the Illinois Raffles and Poker Runs Act (230 ILCS 15/1 et seq.).

ORGANIZATION PRESIDING OFFICER         ORGANIZATION SECRETARY

Name: ______________________________         Name: ________________________________

Signature:____________________________         Signature: _____________________________

STATE OF ILLINOIS       )

) SS

COUNTY OF ST. CLAIR )

I, ________________________, a Notary Public for the State and County aforesaid, do hereby certify that ______________________________________ and ______________________________________, personally known to me to be the same persons whose names are subscribed to the foregoing instrument, appeared before me this day in person and acknowledged that he/she signed and delivered the same instrument as the free and voluntary act for the uses and purposes therein set forth.

Given under my hand and notarial seal this _________________ day of _________________, ________.

_______________________________________

Notary Public

My Commission Expires: ________________________________

 

(1960 Code, § 7-17-1) (Ord. 5385, passed 3-8-1995; Ord. 7887, passed 8-17-2015)