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<br />:;it~~?41tJ\i REPORT ON A CHARITY LOCAL PERMIT <br />\'.'Ii'ia.f/'t..:!U OFFICE OF ATTORNEY GENERAL <br />\~.: ,.tc .;;&;~j SFN 52880 (09-2003) <br />,.::~...... ..........~:I <br />. ''''-;;;;;:i~~ <br /> <br /> <br />Name of Organization <br /> <br />~A e.\~ ~ \:~ <br />'7 <br /> <br />\ <br /> <br />~<..,(~b~ <br />City <br />~~ <br /> <br />Site Name <br /> <br />permit1T33 <br />Date of Event <br />JoI H - Av..) n f ""g- <br /> <br /> <br />Zip Code <br />S8'07~-O <br /> <br /> <br />Gaming Activity <br /> <br />Gross Income <br /> <br />Cost of Prizes <br /> <br />Balance <br /> <br />Expenses <br /> <br />Net Income <br /> <br />$ <br /> <br />~~F\ <br /> <br />$ ~qocr ~ <br /> <br />$ <br /> <br />d4'o9 SO <br /> <br /> <br />$ ~qoq st) <br /> <br />Eligible Use Contributions. Refer to the Backside of the Fonn <br /> <br /> Recipient Description of Use Check Amount <br /> K ;"" ' . -;'119~ <br /> Ocve,1 \ <br />2 )1el-t~ C a..;rn I'V1 ,. OJ) oJ2 <br />3 '}','t"'t'\ P ~~Q,~N r \J/";1')Vo j la~~ <br />4 \~~<::. \"0 c...o.J \...t.A. f I O~ sO <br />5 \C)\"I'\. ll.ov""\d. 1\02 <br />6 0... ((\0 V\\\ r~~l '3>S~ <br />7 d r-JL\.DCN'\ ~ I~.so <br />8 S~N '5\ ~e k t ~ '\ ~ Co.! <br />9 M\o.. \-+v ~e: t SC\~!9 <br />10 .JI'N) -r~\) l,llck.A W"'lne.A P4 lsO <br />11 <br />12 <br /> <br />Total $ ~oq ~ <br /> <br />Note - If the total amount of eligible use contributions is less than the net income, explain: <br /> <br /> <br />Business Phone No. <br />2fl2. - 22tJ() <br /> <br />Instructlons: copy 0 completed report within 30 days of the event to: <br />1. City or County Auditor thai issued the Charity Local Penn It; and <br />2. OFFICE OF ATTORNEY GENERAL; LICENSING SECTION: 600 E BOULEVARD AVE - DEPT 125; BISMARCK NO 58505-0040 <br />