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Form Le-21a - Quarterly Report Bank Account Information - Secretary Of State, State Of Colorado

State of Colorado

LE-21a: Quarterly Report Bank Account Information

Colorado Secretary of State

1700 Broadway, Suite 300

Denver, CO 80290

CONFIDENTIAL, NOT FOR PUBLIC DISTRIBUTION

This form will NOT be scanned for public viewing

1. License Number

2. Quarter Year

3. Quarter

4. Due Date

5. Organization Name

6. Mailing Address

7. City, State, Zip

8. Bank Name:

9. Acct. No.

10. Address:

City:

Zip:

8. Bank Name:

9. Acct. No.

10. Address:

City:

Zip:

(Reminder-Do not put this information into lines 12-15 of the LE-21 as it will be posted to the Internet. Provide bank

account information here and it will be maintained in a separate file. It is public information and can be accessed upon

request but will not be made available to the general public )

LE 21a Quarterly Report Bank Account Information Instructions

1. Enter the current Colorado Bingo/Raffles License Number

2. Enter the quarter year being reported

3. Enter the current quarter

4. Enter the due date

5. Enter the organization's name

6. Enter the organization's address

7. Enter the city, state, and zip code

L:GamesManagerTraining/LE21aGMT-InstrBlankForm/Sept07/dc

Form Le-21a - Quarterly Report Bank Account Information - Secretary Of State, State Of Colorado