61.ql2q1fil eligible organization annual registration … · 2018. 12. 10. · state of california...

$: 61.Ql2Q1fil ELIGIBLE ORGANIZATION ANNUAL REGISTRATION … · 2018. 12. 10. · state of california departmentof justice bgc200 (rev.--mg'\61.ql2q1fil major league sports raffle$
STATE OF CALIFORNIA DEPARTMENTOF JUSTICE BGC200

PAGE 1 of2 (Rev--MG61Ql2Q1fil MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION ANNUAL REGISTRATION FORM

FOR CALENDAR YEAR 20 For Official Use Only

MAIL TO CT Status Bureau of Gambling Control

PO Box 168024 Sacramento CA 95816-8024

FTB Status

Phone (916) 830-1700 sos Status

Pursuant to California Penal Code section 3206 this form shall be used by eligible organizations to apply for a registration issued by the Department of Justice Please type or print (in ink) all information requested on this form A nonrefundable $5009 14400 Annual Registration Fee must accompany this form Make check or money order payable to the California Department of Justice

SECTION 1 ORGANIZATION INFORMATION

Provide at least one of the following numbers Name of Organization

Federal Tax ID

Corporate Address no and street name

Organization

Charitable Trusts

Is the organization qualified to conduct City business in the State of California at least one

State Zip Code

year prior to first raffle DYES ONO

Team or Association Affiliation Phone Number E-Mail Address (if applicable)

SECTION 2 TAX EXEMPT STATUS

Specify the organizations tax exempt status pursuant to California Revenue and Taxation Code section

D 23701a D 23701b D 23701d D 23701e D 237011 D 23701g D 23701k D 237011 D 237011 D 23701w Ha~ the organization applied for or been granted IRS tax exempt status D YES ONO

I

Date of application for IRS tax exemption I IOR Date of exemption letter I I SECTION 3 FIDUCIARY INFORMATION

(Person with legal authority to make financial decisions on behalf of the eligible organization and ensure compliance with the Majot League Spotts Raffle Program)

First Name Last Name Middle Initial

Title Date

SECTION 4 CERTIFICATION I declare under penalty of perjury under the laws of the State of California that the foregoing information and all information submitted with this application is true correct and complete I declare that our organization has been qualified to conduct business in the State of California for at least one year prior to the first raffle to be held this calendar year Additionally our organization and its representatives agree to comply with all applicable laws and administrative regulations regarding the conduct of major league sports raffle(s) in the State of California


Fiduciarys Printed Name

Fiduciarys Signaturemiddot----------------------- Date

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGC200 (Rev-8104il 1Ql2Q1fil MAJOR LEAGUE SPORTS RAFFLE PAGE 2 of 2

ELIGIBLE ORGANIZA TION ANNUAL REGISTRATION FORM

Privacy Notice on Data Collection Forms As Required by Civil Code sect 179817

Collection and Use of Personal Information The Division of Law Enforcement Bureau of Gambling Control in the Department of Justice collects the information requested on this form as authorized by California Penal Code section 3206 The Bureau uses this information to establish grounds for the license permit or other approval indicated on this application form In addition any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy The Department of Justices general privacy policy is available at httpoagcagovpr ivacy-policy

Providing Personal Information All the personal information requested in this form must be provided

Access to Your Information You may review the records maintained by the Division of Law Enforcement Bureau of Gambling Control in the Department of Justice that contain your personal information as permitted by the Information Practices Act (See below for contact information )

Possible Disclosure of Personal Information In order to process your applicat ion we may need to share the information you give us with law enforcement or regulatory agencies

The information you provide may also be disclosed in the following circumstances

With other persons or agencies where necessary to perform their legal duties and their use of your information is compatible and complies with state law such has for investigat ions or for licensing certification or regulatory purposes

To another government agency as required by state or federal law

Contact Information For questions about this notice or access to your records you may contact the Special Agent Supervisor of Special Programs at the Department of Justice Bureau of Gambling Control at P 0 Box 168024 Sacramento CA 95816-8024 (916) 830-1700 or e-mail at GamblingControldoj ca gov


PAGE 1 of3 (Rev eme~ ~ MAJOR LEAGUE SPORTS RAFFLE MANUFACTURER AND DISTRIBUTOR OF PRODUCTS OR SERVICES

ANNUAL REGISTRATION FORM FOR CALENDAR YEAR 20

MAIL TO Bureau of Gambling Control

P 0 Box 168024 Sacramento CA 95816-8024

Phone (916) 830-1700

Pursuant to California Penal Code section 3206 manufacturers and distributors who provide raffle-related products or services to eligible organizations that conduct major league sports raffle(s) must register annually with the Department of Justice This form shall be used by manufacturers and distributors who provide raffle-related products or services to apply for registrBtion with the Department of Justice

Please type or print (in ink) all information requested on this form A $5000 432000 Annual Registration Fee must accompany this form Make check or money order payable to the California Department of Justice

SECTION 1-ENTITY INFORMATION

Applicants First Name Last Name Middle Initial Title

Business Name Doing Business As (if different than Business Name)

Business Address (no and street name) City State Zip Code Business Telephone Number

I I Mailing Address (no and street name) City State Zip Code Business Fax Number

I I City or County of Business License Business License or Tax Certificate Number Business License Expiration Date

Federal Tax ID E-Mail Address (if applicable) Website Address (if applicable)

SECTION 2 RAFFLE-RELATED PRODUCTS AND SERVICES

Please indicate the products andor services that the business provides

D Electronic Accounting amp Reporting System Software D Electronic Raffle Ticket Sales Printer

D Electronic Accounting amp Reporting System D Electronic Raffle Ticket Paper

D Electronic Raffle System Security Component D Counterfoil Container

D Electronic Raffle System Server D Admission-style Raffle Tickets

D Electronic Raffle System Server Software D Wide Area Network Component

D Electronic Raffle Ticket Sales Device

Other I I

--------

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGC201 PAGE2of3(Rev e22fl--t-1-102018) MAJOR LEAGUE SPORTS RAFFLE

MANUFACTURER AND DISTRIBUTOR OF PRODUCTS OR SERVICES ANNUAL REGISTRATION FORM

SECTION 3 MANUFACTURER LICENSE INFORMATION If additional space is needed please attach a listing of the requested information on a separate sheet of paper

Has the equipment being registered been licensed with any gaming agency including any other state city county federal or country agency

Yes Please list the gaming agency and 0No D license information in the following table

Gaming Agency Name License Number from that Agency Expiration Date

I declare under penalty of perjury under the laws of the State of California that the foregoing information and all information submitted with this application is true correct and complete Additionally our business and its representatives agree to comply with all applicable laws local ordinances and administrative regulations concerning major league sports raffles in the State of California


Printed Name

DateSignature -------------------

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGC201

PAGE 3 of 3 (Rev Gm047 1Qallsect) MAJOR LEAGUE SPORTS RAFFLE MANUFACTURER AND DISTRIBUTOR OF PRODUCTS OR SERVICES

ANNUAL REGISTRATION FORM

Privacy Notice on Data Collection Forms As Required by Civil Codesect 179817

Collection and Use of Personal Information The Division of Law Enforcement Bureau of Gambling Control in the Department of Justice collects the information requested on this form as authorized by California Penal Code section 3206 The Bureau uses this information to establish grounds for the license permit or other approval indicated on this application form In addition any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy The Department of Justices general privacy policy is available at httpoagca govprivacy-policy


Access to Your Information You may review the records maintained by the Division of Law Enforcement Bureau of Gambling Control in the Department of Justice that contain your personal information as permitted by the Information Practices Act (See below for contact information)

Possible Disclosure of Personal Information In order to process your application we may need to share the information you give us with law enforcement or regulatory agencies


With other persons or agencies where necessary to perform their legal duties and their use of your information is compatible and complies with state law such has for investigations or for licensing certification or regulatory purposes


Contact Information For questions about this notice or access to your records you may contact the Special Agent Superv isor of Special Programs at the Department of Justice Bureau of Gambling Control at P 0 Box 168024 Sacramento CA 95816-8024 (916) 830-1700 or e-mail at GamblingControldojcagov


PAGE 1 of2 (Rev 921291-7 102018) MAJOR LEAGUE SPORTS RAFFLE MANUAL DRAW SUPERVISOR ANNUAL REGISTRATION FORM

FOR CALENDAR YEAR 20



Phone (916) 830-1700

Pursuant to California Penal Code section 3206 person(s) affiliated with the eligible organization who supervise the manual draw must register annually with the Department of Justice This form is to-be used by an eligible organization to register person(s) who will supervise the manual draw

Please type or print (in ink) all information requested on this form A nonrefundable $-W21Annual Registration Fee for each Manual Draw Supervisor listed in Section 2 must accompany this form Make check or money order payable to the California Department of Justice

SECTION 1 INFORMATION

Eligible Organization Team or Association Affiliation

Fiduciarys First Name Last Name Middle Initial Daytime Telephone Number

Eligible Organization Address (no and street name) City State Zip Code

Mailing Address if different (no and street name) City State Zip Code

I

SECTION 2 MANUAL DRAW SUPERVISOR

I -- -

I IMiddle I Employees

First Name Last Name Initial

Government Type Issuing Agency Issued ID

I 11 CJI I 11

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11 CJ I 11

11 CJ I I I 11 CJ I I

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STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGC 202

PAGE 2 of2 102018) (Rev GiliG-11 MAJOR LEAGU E SPORTS RAFFLE MANUA L DRAW SUP ERVISOR ANNUAL REGISTRATION FORM

SECTION 3 CERT IFICATION

I declare under penalty of perjury under the laws of the State of California that the foregoing information and all information submitted with this application is true correct and complete I understand that the information I have provided on this form will be verified with the eligible organization as part of the registration process I agree to comply with all applicable laws local ordinances and admini strative regulati ons concerning major league sports raffles in the State of California



Fiduciarys Signature -------------------- Date

Privacy Notice on Data Collect ion Forms As Required by Civil Code sect 1798 17

Collection and Use of Personal Information The Division of Law Enforcement Bureau of Gambling Control in the Department of Justice collects the information requested on this form as authorized by California Penal Code section 320 6 The Bureau uses this information to establish grounds for the license permit or other approval indicated on this applicat ion form In addition any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy The Department of Justices general privacy policy is available at httpoag cagovprivacy -policy

Providing Persona l Information All the personal information requested in this form must be provided


Possible Disclosure of Personal Information In order to process your application we may need to share the informa tion you give us with law enforcement or regulatory agencies




Contact Information For questions about this notice or access to your records you may contact the Special Agent Supervisor of Special Programs at the Department of Justice Bureau of Gambling Control at P 0 Box 168024 Sacramento CA 95816- 8024 (9 16) 830-1700 or e-mail at GamblingControldoj cagov

DEPARTMENT OF JUSTI

MAJOR LEAGUE SPORTS RAFFLE PAGJ of 4 RE P EAL ELIGIBLE ORGANIZATION ANNUAL REPORT PLEASE SEND COMPLETED REPORT TO Bureau of Gambling Control P 0 Box 168024

~~nto CA 95816-8024 Phomiddot~ 6-830-1700

Annual Report Period

Eligible__Organizations Name --- ---------- -------- --- ------- -- -

Eligible Organizations Registration Nu~

Pursuant to Penal Code section 3206 bdivision (o)(12)(A) once registered an eligible organi ion shall file annually thereafter with the Department of Justice a report that incl es all of the following information for each of the 1gible organizations last three fiscal years

Pursuant to Penal Code section 320 6 subdivi middot n (o)(12)(B) failure to submit the annual port shall be grounds for denial of an annual registration

Year1

to

Year2

to

Year3

to REGULATIONSTATUTE

(i) The aggregate gross receipts from the operation of raffles

(ii) The aggregate direct costs incurred by the eligible organization from the operation of raffles

(iii) The charitable or beneficial purposes for which proceeds of the raffles were used

(iv) The aggregate distributions of proceeds from the operation of raffles made to directly support benefici charitable purposes other than beneficial or chari le purposes undertaken by the eligible organizati or eligible recipient organizations under Penal Code ction 3205 subdivision (c)

(v) The aggregate distributions centproceeds from the operation of raffles made to affle winners

(vi) The aggregate di utions of proceeds from the operation of raffle ade to any other organizations or for any other purp es other than those included in items (ii) (iv) and (v

DEPARTMENT OF JUSTI

MAJOR LEAGUE SPORTS RAFFLE PAG~ of4

ELIGIBLE ORGANIZATION ANNUAL REPORT

Year 2

to

Year 3

to

REGULAT IONSTATUTE

(vii) A schedule of distrib middot ns of proceeds from the operation of raffles by indivi I raffle made to eligible recipient organizations under Pe I Code section 320 5 subdivision (c) that are not affiliate ith the eligible organization

(viii ) A schedule of distributions of proceeds operation of raffles by individual raffle made to recipient organizations under Penal Code section 3 subdivision (c) that are affiliated with the eligible organization

(ix) A schedule of distributions of proceeds from the operation of raffles by individual raffle made to any other organization not included under items (vii) or (viii) above or for beneficial or charitable purposes undertaken by the eligible organization

(x) The aggregate gross receipts from activities other than the operation of raffles

(xi) The aggregate costs incurred by the eligible organization from activ ities other than the operation of raffles

(xii) The aggregate distributions of funds other th proceeds from the operation of raffles made to directly pport beneficial or charitable purpos es or eligibl ecipient organizations under Penal Code sectio 320 5 subdivision (c)

(xiii) The aggregate distributi s of funds other than proceeds from the operaf of raffles for purposes other than those listed in ite s (xi) and (xii) above

Year 1

to

DEPARTMENT OF JUSTJ

PAG0 of 4 MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZAT ION ANNUAL REPORT

REGULATIONSTATUTE

(xiv) A schedule of distribution f funds other than proceeds from the operation of raffles made eligible recipient organizations under Penal Code sect ~ 3205 subdivision (c) that are not affiliated with the eligibleeqanization

(xv) A schedule of distributions of funds other th~ roceeds from the operation of raffles made to any other ~rg~ ation not included under item (xiv) above or for beneficial or charitable purposes undertaken by the eligible organizatio

Year1

to to

Year2 Year3

to

NOTE The department shall make the reports required by this rag rap vai lable to the public via the on line search portal of the Attorney Generals Registry of Charitable Trusts maintained pursua Section 12584 of the Government Code

CERTIFICATION

I declare under penalty of perjury under the laws o_Jttle State of California that the foreg-Qing information is true correct and complete

First Name Last Name - Middle Initial


Fiduciarys Signature ____ __________________ _ Date - -lt------- ------

DEPAR TMENT OF JUSTI

MAJOR LEAGUE SPORTS RAFFLE PAGJi(ot 4



Collection and Use of Per The Division of Law Enforceme Bureau of Gambling Control in the Department of Justice collects the il)formation requested on this form as authorized by California Penal de section 3206 The Bureau uses this information to establish rounds for the license permit or other approval indicated on this applic middoton form In addition any personal information collected b tate agencies is subject to the limitations in the Information Practices Ac nd state policy The Department of Justices gener privacy policy is available at httpoag cagovprivacy-policy

Providing Personal Information All the personal information requested in this form must~ provided

Access to Your Information You may review the records maintained by the Division of Law Enfuzccentent Bureau of Gambling Control in the Department of Justice that contain your personal information as permitted by the Information ~ces Act (See below for contact information)

Possible Disclosure of Personal Information In order to process your application we may need to sh the information you gi(e us with law enforcement or regulatory agencies

The information you provide may also be disclos~n the following circumstances

With other persons or agencies wh~ necessary to perform their legal duties and thei~e of your information is compatible and complies with state law such hayfor investigations or for licensing certification or regulat~ purposes

To another government a_gency as required by state or federal law

Contact Information For questions about t middot notice or access to your records you may contact the Special Agent Supervisor of SpeciaNfograms at the Department of Jus middot e Bureau of Gambling Control at P 0 Box 168024 Sacramento CA 95816-8024 (916) 830-1700 or e-mail at Gamblin Contr domiddotca ov

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGC 203 PAGE 1 of4 (Rev 102018) MAJOR LEAGUE SPORTS RAFFLE

ADOPT ELIGIBLE ORGANIZATION RAFFLE REPORT PLEASE SEND COMPLETED REPORT TO Bureau of Gambling Con trol P 0 Box 168024 Sacramento CA 95816-8024

Phone 916-830-1700

Raffle Report Period D Season or D Calendar Year Dates

Eligible Organizations Name ------ ------- --- -- ---- --------- --

Eligible Organizations Registration Number

Pursuant to Penal Code section 3206 subdivision (o)(13)(A) once registered an eligible organization shall file with the Department of Justice each season or year thereafter a report that includes all of the following information Pursuant to Penal Code section 3206 subdivision (o)(13)(B) failure to submit the seasonal or annual report shall be grounds for denial of an annual registration and for the imposition of penalties under Government Code section 125911

SECTION 1 SEASON OR ANNUAL RAFFLE TOTALS

Total number of raffles conducted for the season or calendar year

The gross receipts generated from the sale of raffle tickets for the season or calendar year

The average per raffle gross receipts generated from the sale of raffle tickets for the season or calendar year

The prize total for the season or calendar year including any prize that was not claimed

The average per-raffle prize total for the season or calendar year including any prize that was not claimed

The prize total that was not claimed if any during the season or calendar year

For each raffle in which the raffle prize was not claimed list the name of the eligible recipient organization that received the prize (attach additional sheets if needed)


(Rev 1012018) MAJOR LEAGUE SPORTS RAFFLE PAGE 2of4

ADOPT ELIGIBLE ORGANIZATION RAFFLE REPORT

SECTION 2 COST RELATED INFORMATION

Provide a total of the di rect costs of conducting the raffles for

Labor Consulting Software Marketing Equipment

Provide a schedule of vendors used to operate the raffles and total payment s made to each vendor Attach additional sheets if needed) Amount Paid

STATE OF CA LIFORNIA DEPA RTMENT OF JUSTICE BGC 203

(Rev 102018) MAJOR LEAGUE SPORTS RAFFLE PAGE 3 of 4


SECTION 3 FOR EACH RAFFLE EVENT PLEASE PROVIDE THE FOLLOWING INFORMATION (attach additional sheets if needed)

Prize Status Amount Each Registered Benefitting Organization (Eligible Organization or Eligible Gross Receipts Winning Ticket Event Date Organization (ClaimedEvent ID Recipient Organization) (Tickets Sold) NumberReceived Unclaimed)

CERTIFICATION

I declare under penalty of perjury under the laws of the State of California that the foregoing information is true correct and complete First Name Last Name Middle Initial


Fiduciarys Signature Date __ _______ _ _ __ _


PAGE 4 of 4(Rev 1012018) MAJOR LEAGUE SPORTS RAFFLE



Collection and Use of Personal Information The Division of Law Enforcement Bureau of Gambling Contro l in the Department of Justice collects the information requested on this form as authorized by California Penal Code section 3206 The Bureau uses this information to establish grounds for the license permit or other approval indicated on this application form In addition any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy The Department of Justices genera l privacy policy is availab le at httpoag cagovprivacy-policy




The information you provide may also be disclosed in the follow ing circumstances

With other persons or agencies where necessary to perform thei r legal duties and their use of your information is compatible and complies with state law such has for investigations or for licensing certification or regulatory purposes


Contact Information For questions about this notice or access to your records you may contact the Special Agent Supervisor of Special Programs at the Department of Justice Bureau of Gambling Control at P 0 Box 168024 Sacramento CA 95816-8024 (916) 830-1700 or e-mail at GamblingControldojcagov

STATE OF CALIFORNIA DEPARTMENTOF JUSTICE BGC 204 (RevGm84-7-1012QW PAGE1of2

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION RAFFLE REGISTRATION FORM




Phone (916) 830-1700

Pursuant to California Penal Code section 3206 an eligible organization that wishes to conduct major league sports raffle(s) must register the raffle(s) with the Department of Justice This form is for the registration of raffle(s) for regular season and post-season home games

Please type or print (in ink) all information requested on this form A nonrefundable $400 200 Registration Fee for each raffle listed in Section 2 must accompany this form Make check or money order payable to the California Department of Justice

SECTION 1 ELIGIBLE ORGANIZATION INFORMATION


Fiduciary First Name Last Name Middle Initial Daytime Telephone Number


I

Mailing Address (no and street name) City State Zip Code E-Mail Address (if applicable)

I I SECTION 2 RAFFLE REGISTRATION

If additional space is needed please attach a listing of the requested information on a separate sheet of paper

I Name of Private Non-Profit Eligible Organization For I Federal Tax ID

Event Date Event Location Which Raffle Is Being Conducted (if event to support another

organization)

II 11 11 I

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STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGC 204 (Rev 82f28+7 1Q2llli ) PAGE 2of2


SECTION 3 CERTIFICA TION

I declare under penalty of perjury under the laws of the State of California that the foregoing information and all information submitted with this application is true correct and complete I understand that the information that I have provided on this form will be verified with the eligible organization as part of the registration process I agree to comply with all applicable laws local ordinances and administrative regulations concerning major league sports raffles in the State of California



Fiduciarys Signature ----~~-------------- Date

Privacy Notice on Data Collection Forms As Required by Civil Code sect 1798 17

Collection and Use of Personal Information The Division of Law Enforcement Bureau of Gambling Control in the Department of Justice collects the information requested on this form as authorized by California Penal Code section 3206 The Bureau uses this information to establish grounds for the license permit or other approval indicated on this application form In addition any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy The Department of Justices general privacy policy is available at http oag cagov privacy -policy







Contact Information For questions about this notice or access to your records you may contact the Special Agent Supervisor of Special Programs at the Department of Justice Bureau of Gambling Control at P 0 Box 168024 Sacramento CA 95816-8024 (916) 8301700 or e-mail at GamblingControldojca gov

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGC200 (Rev-8104il 1Ql2Q1fil MAJOR LEAGUE SPORTS RAFFLE PAGE 2 of 2

ELIGIBLE ORGANIZA TION ANNUAL REGISTRATION FORM


Collection and Use of Personal Information The Division of Law Enforcement Bureau of Gambling Control in the Department of Justice collects the information requested on this form as authorized by California Penal Code section 3206 The Bureau uses this information to establish grounds for the license permit or other approval indicated on this application form In addition any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy The Department of Justices general privacy policy is available at httpoagcagovpr ivacy-policy



Possible Disclosure of Personal Information In order to process your applicat ion we may need to share the information you give us with law enforcement or regulatory agencies


With other persons or agencies where necessary to perform their legal duties and their use of your information is compatible and complies with state law such has for investigat ions or for licensing certification or regulatory purposes


Contact Information For questions about this notice or access to your records you may contact the Special Agent Supervisor of Special Programs at the Department of Justice Bureau of Gambling Control at P 0 Box 168024 Sacramento CA 95816-8024 (916) 830-1700 or e-mail at GamblingControldoj ca gov






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61.ql2q1fil eligible organization annual registration … · 2018. 12. 10. · state of california...

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