Date: _____________________
Name/Address of Organization: _________________________________________________________________________
Phone: ______________________________________ Email Address: ______________________________________
Type of Organization: _________________________________________________________________________________
(Religious, charitable, labor, fraternal, veterans, etc.)
1. Is the organization a charitable organization which is a 501(C)(3) organization as defined by the United States Internal Revenue Service? PLEASE CIRCLE ONE
Yes - No fee unless item retail is over $1,000 (Must provide a copy of IRS determination letter.)
No - If no, see below
2. Is the aggregate retail value of all prizes or merchandise to be awarded by a licensee in a single raffle less than $1,000.00? PLEASE CIRCLE ONE
YES-A fixed fee of $25.00
No - A fixed fee $50.00 per raffle
In making this Application, the above-named organization states as follows:
1. That the geographic area in which the raffle is to be conducted is within the boundaries of the corporate limits of the Village of Brighton.
2. The aggregate retail value of all prizes/merchandise $_______________________________________________
3. The maximum retail value of each prize awarded $_________________________________________________
4. The cost of raffle chance $_____________________________________________________________________
5. Beginning date of sale of raffle chances__________________________________________________________
Ending date of sale of raffle chances_____________________________________________________________
6. Place/Address of Raffle________________________________________________________________________
7. Proceeds of raffle will be used for:_____________________________________________________________
8. Names of persons conducting the raffle:
• _____________________________________________________
• _____________________________________________________
• _____________________________________________________
9. Addresses where raffle tickets will be sold:________________________________________________________
____________________________________________________________________________________________
Signature of Applicant: ______________________________________________________ Date: _____________________
Approved By: _____________________________________________________________ Date: _____________________
VILLAGE OF BRIGHTON
APPLICATION FOR RAFFLE LICENSE
SWORN STATEMENT
The following officers attest to the not-for-profit character of the applicant organization.
_____________________________________________________________________________________________________
(NAME OF ORGANIZATION)
Dated this _______________________ day of __________________________________, ________.
____________________________________________
PRESIDING OFFICER
____________________________________________
SECRETARY
STATE OF ILLINOIS )
) ss.
COUNTIES OF JERSEY AND MACOUPIN )
Signed and sworn to before me this _______________ day of ________________________________, ______.
___________________________________________ ________________________________________________
PRESIDING OFFICER SECRETARY
________________________________________________
NOTARY PUBLIC