Games Of Chance Lottery Financial Report (F/r)
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1
2Organization RSN__________
Office use
Games of Chance
only
Property RSN
__________
Folder RSN
_____________
Lottery Financial Report (F/R)
Entered
______________
________________________________________________________________________________________________________________________
Licencee
Licence Information
Organization Name:__________________________________________
Licence Number: ____________________________________________
__________________________________________________________
Mailing Address: ____________________________________________
Report Period:
__________________________________________________________
From: _____________________________________________________
City/Town: _________________________________________________
To: _______________________________________________________
Province: ________________ Postal Code: _______________________
Phone: ____________________ Fax: ___________________________
Use of Proceeds
Provide detailed as to how proceeds were used: (Attach a separate sheet if necessary.)
Net Proceeds (In $)
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Total Net Proceeds:
To be signed by a Principal Officer of the Organization & the Person Completing this financial report.
We certify that this Financial Report and all accompanying documents are true and correct statements of the above lottery activity.
Principal Officer
Person Completing Financial Report
Name: ____________________________________________________
Name: ____________________________________________________
Position: __________________________________________________
Position: ___________________________________________________
Address: __________________________________________________
Phone (W): __________________ Phone (H): _____________________
__________________________________________________________
Signature: _________________________________________________
City/Town: _________________________________________________
Date: _________________
Province: ____________________ Postal Code: ___________________
Phone (W): __________________ Phone (H): _____________________
Signature: _________________________________________________
Date: ___________________
Reminder
Licence fee is 1% of the amount of retail value of prize paid out during a card game or $5 per each wheel or game per event.
The Financial Report is to be signed by a principal officer of your organization. i.e. president, vice president, treasurer.
Make cheques payable to “Newfoundland Exchequer”.
Keep a copy of this report for your records.
The Financial Report is due 60 days after the expiry date of your licence. If stated on the back of your licence.
Failure to file a Financial Report may affect your organization’s ability to obtain future licences.
All records for the lottery must be retained for a period of 6 years after the expiry date of your licence.
Financial Report can be dropped off at any
149 Smallwood Drive, P.O. Box 8700, St. John’s, NL, A1B 4J6
Service Centre or Mailed to:
Phone: (709) 729-2660 or 1-877-968-2600 Fax: 1 (709) 729-6998
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