New Jersey Ofce 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
Instructions for Filing the Rafe Report of Operations
PursuanttoN.J.A.C.13:47-9.1,licenseesmustleareportofoperationswiththeLegalizedGamesofChance
ControlCommissionnolaterthanthe15thdayofthecalendarmonthimmediatelyfollowingthecalendarmonthin
whichthelicensedactivitywasheld,operatedorconducted.
YoumustdownloadthisreportandcompleteALLoftheentriesforeachoccasion(s)relatingtotheconductof
allrafes,exceptforinstantrafegamesandcarnivalgamesandwheels.Oncecompleted,amember/ofcermust
certifythathe/shehasreviewedthereportandthattheinformationprovidedistrue,accurateandcomplete.This
willrequirethepersontostatehis/hernameandtitle,andthatpersonmustcompletetheinformationonpage3and
havethereportnotarized.
TheRafeReportofOperationsfortheconductofoff-premises50/50ormerchandiserafesistobeaccompanied
withasampleticket.ReportsaretobemailedtoLegalizedGamesofChanceControlCommission,P.O.Box46000,
Newark,NewJersey07101,oremailedtoAskGames@dca.njoag.gov.
Itisrecommendedthatyoumaintainacopyofallreportsaspartoftheorganization’srecords.
New Jersey Ofce 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
Rafe Report of Operations
Please print clearly.IdenticationnumberIRUPDW_____________________
Municipality______________________________________ Licensenumber______________________
Nameoflicensee_____________________________________________________________________________
Organization
___________________________________________________________________________________________
Streetaddress City State ZIPcode
Locationofgames____________________________________________________________________________
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
ChanceControlCommissionnolaterthanthe15thdayofthemonthfollowingtheconductofthegame(s)ofchance.
Occasion 1 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold  ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________


7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 2 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold  ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________
 
 7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 3 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold  ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________


7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 4 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold  ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________


 7.Totalexpenses $__________ 8.Netproceeds $_________

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E-Mail Form
Clear Form
Occasion 5 Date ____________________ Time_____________________ Typeofrafe______________
1.Numberofticketssold  ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________


7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 6 Date _______ Time_________ Typeofrafe _________
1.Numberofticketssold  ___________ 4.Costofprizes $__________ Typeofprize(s)_____________
2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________
3.Grossreceipts $___________ 6.Otherexpenses $__________
(Ifneeded,attachseparatesheet)

7.Totalexpenses $__________ 8.Netproceeds $_________

Totalnumberofoccasions.................................. _________
Totalnumberofticketssold(1-6combined)...... _________
Priceoftickets..................................................... $ ________
Totalgrossproceeds(1-6combined).................. $ ________
Totalexpenses(1-6combined)........................... $ ________
Totalnetproceeds(1-6combined)...................... $ ________
Date
Schedule of Expenses
Description Checknumber
Amount
Date
Utilization of Net Proceeds
Description Checknumber
Amount
0
$ 0.00
$ 0.00
$ 0.00
0
$ 0.00
$ 0.00
$ 0.00
0
$ 0.00
$ 0.00
$ 0.00
Name
Bank
Addresswherebalanceisdeposited
Accountnumber
Name
Person Responsible for Use of Proceeds
Address
Telephonenumber
(includeareacode)
Icertifythatallofthestatementsonthisreportofoperationsaretrue,accurateandcomplete.Iamaware
thatifanyoftheforegoingstatementsarewillfullyfalse,Iamsubjecttopunishment.
N.J.S.A.5:8-37“Itshallbethedutyofeachlicenseetomaintainandkeepsuchbooksandrecordsasmay
benecessarytosubstantiatetheparticularsofeachsuchreport.”
I certifythatI have reviewed this report and that the information on this report of operations is true,
accurateandcomplete.Iamawarethatifanyoftheforegoingstatementsarewillfullyfalse,Iamsubject
topunishment.
I certify by placing a check in this
box, that I have reviewed the report and that the information
provided is true, accurate and complete.
Youmuststateyournameandtitlebelow.Reportsthatarenotproperlycertiedwillbeemailedback.
_______________________________________ __________________________________________

Nameandtitleofofcer(pleaseprint) Signatureofofcer
Swornandsubscribedtobeforemethis__________
dayof ______________________ ,____________
__________________________________________

NameofNotaryPublic(pleaseprint)
__________________________________________

SignatureofNotaryPublic
MonthYear
Afx Seal Here
Form LGCCC 8R-A (Rev. 4/6/16v2)
Prizes Offered or Awarded
Pleaselisttheprizesofferedorawardedandtheirrespectiveretailvalues.
PrizesOfferedorAwarded RetailValue
PrizesOfferedorAwarded RetailValue