Form Wv/raf-3 - Annual Raffle Financial Report Form Page 2

LISTING OF CHECKS PAID OUT OF RAFFLE FUNDS

USE ADDITIONAL SHEETS IF NECESSARY

(PLEASE NOTE: ALL CHECKS PAID OUT OF RAFFLE ACCOUNT MUST BE LISTED BEFORE RETURN CAN BE ACCPETED)

Check Number

Date

Payee

Purpose of Check

Dollar Amount

THE FINANCIAL RETURN MUST BE CERTIFIED BY A CERTIFIED PUBLIC ACCOUNTANT OR BY A LICENSED

PUBLIC ACCOUNTANT IF LINE 5 (GROSS PROCEEDS) EXCEEDS $50,000.00.

I, ______________________________________, as an authorized representative of _________________________________,

(Licensed Organization)

certify or affirm that the statement and items entered herein and attached are true and correct to the best of my knowledge.

__________________________ ______________________________________________

_________________________

Date

Signature

Title

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Parent category: Legal