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Form Gc-7q - Quarterly Statement Of Bell Jar Operations - Nys Gaming Commission - Division Of Charitable Gaming Page 2

E. AFFIRMATION

All three sections must be signed

Unsigned reports will be returned.

I swear or affirm that the information and statements contained herein have been examined by me and

. (Pursuant to Commission Rule 4624.6, “if the financial statement of bell jar

are true, accurate and complete

operations filed by a licensee is not properly verified, or not fully, accurately and truthfully completed, no further

license shall issue to it, and any existing license may be suspended”.)

Head of Organization:

___________________________________________________ ___________________

Signature

Date

_________________________________________________ ______________________________________________

Print Name

Print Title

__________________________________________________________________ (______)____________________

Home Address, City and Zip Code

Phone Number

____________________________________________________

Email Address

Preparer of Report:

___________________________________________________ ___________________

Signature

Date

_________________________________________________ ______________________________________________

Print Name

Print Title

__________________________________________________________________ (______)____________________

Home Address, City and Zip Code

Phone Number

____________________________________________________

Email Address

Member In Charge:

___________________________________________________ ____________________

Signature

Date

_________________________________________________ ______________________________________________

Print Name

Print Title

__________________________________________________________________ (______)____________________

Home Address, City and Zip Code

Phone Number

____________________________________________________

Email Address

F. FINANCIAL INFORMATION

If your organization holds bell jar money in additional accounts (such as CD or savings), enter the name of the

financial institution(s), respective account number(s) and the amount held in each account. Use additional paper if

necessary.

Financial Institution: _____________________________ Acct.#: __________________ Balance $: ________________

Financial Institution: _____________________________ Acct #:___________________ Balance $:________________

Financial Institution: _____________________________ Acct #:___________________ Balance $_________________

P.O. Box 7500, Schenectady, NY 12301-7500

Page 2 of 2

(rev. 6/2015)

Form Gc-7q - Quarterly Statement Of Bell Jar Operations - Nys Gaming Commission - Division Of Charitable Gaming Page 2

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