New Jersey Ofce of Attorney General
Division of Consumer Affairs
Legalized Games of Chance Control Commission
124 Halsey Street, 6th Floor, P.O. Box 46000
Newark, New Jersey 07101
(973) 273-8000
Rafe Report of Operations
Please print clearly.IdenticationnumberIRUPDW_____________________
Municipality______________________________________ Licensenumber______________________
Nameoflicensee_____________________________________________________________________________
Organization
___________________________________________________________________________________________
Streetaddress City State ZIPcode
Locationofgames____________________________________________________________________________
This report, as required by N.J.S.A. 5:8-37 and N.J.A.C. 13:47-9, must be led with the Legalized Games of
ChanceControlCommissionnolaterthanthe15thdayofthemonthfollowingtheconductofthegame(s)ofchance.
Occasion 1 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________
Occasion 2 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________
Occasion 3 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________
Occasion 4 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________
7.Totalexpenses $__________ 8.Netproceeds $_________