88-349 �Nli1TE - CITY GLERK
PINK - FINANCE COVIICII y/�
BLUERV - MAPORTMENT GITY OF SAINT PAUL File NO. `� �J��� -
Coun�t Resolution
3�
Presented By
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D. 84773) for the renewal of a State Class
A Gambling License by 5 . Mary's Romanian Orthodox Ladies
Auxiliary at 1494 North Dale Street be and the same is hereby
approved/denied.
COUNCIL MEMBERS
Yeas Nays Requested by Department of:
Dimond
I.ong In Fav r
Goswitz
Scheibcl �` A gai n s t BY
Sonnen
�Ison
Adopted by Council: Date
MAR �' 8 1 Form Appro ed y ity At n
Certified Pas� n il��;�� BY
�
B�r J
Approv �Vtavor: Date
��`���� � �; '�f� Approved by Ma r for Submission to Council
B — BY
PUBII��E� �,��:�',;: �. � 1988
�,,,,�. o„� ,� �„��.,,� - ����`p
. - GR��� ��EEi" �. 4�0 9 8�
; ,J�� F. �
c�r1r"cr _ o�+r pr� . w�roa roa�own .
C�'iY'lStlt]E.' ZP.� ASSiG F� '— Frw�c�a�xr�cinec�oa �, cm a.�
, . — euooEr ox�cran 2 Cb��Y1Cf1 R'L�ed�'C�'1
Finaryoe & t. 298 5456. oa � ��,;� �
�.1. lication for a State of _, .ta C�aritab�].e Class "A" C�a�nbling L�.ce��e.
1��I CN L1ATE: 2/22/88 s 3/8/88
�E (a)«Rel�ct(R)) C01N1C� �@MCN
PLANNNO � GVIL SERVICE COA�MN861QN . .. DA7E IN � , .OA7E� . . � PF7diE NO. . �. .
�iMNO Cqd�ION . 19D 626 9CIIOOL BOAM � .. . . . � � . .
. . $d1i� � � � � � CF1�tER(�N�9810N � A3�8 . 'AODL • � � AET4 7�b OOPRA�T,� . � : . �
. . . . . . __ . . . _iOW ADD'L MIFO. _f�OBAdC/�•. .
DIBIfiCT COUNC0. ��
�.ffiIPrORT8 VNiIG1 COIA�IC9. 4 . . . �. . � . . .. . _ . . .
Council Resear�h Center
FEB 2�1988
r.�►�.�.�, ��.,�.,�.�.;M»�..��; _
1+�. Eileen to, c� behalf of St. Ma�.y s �cxt�anian O�ttxx�oac Iadies P�xi.liary, request:,s
. , Co�a,3: of thei� ren�l a��ica 'oa� `for`a Sfiate .of Minnesota C�arit�le Gmnbling
Litiens�. A "A" License"allt�ws both $ir� ancl'Pulita2�s. 'I?�e �essiCans ax'e h�1d on : :.
�.'ue�d�a�r �}jetvaeen the h�xxzrs of 7:3 p.pn. ar�d �.1.:30 p.m. at 1494 North Y�a].e Street.
P a are u,�eci to assist the pa�ish .'
.�usr�+c�►nou �.�.�...�m�: _ . ; =.: _
All requi� apPlicatic�s ar�d fees ha�+e sutmitted. If C�iu�.i.l a�aval i� granted, ;
St. Mary`s ian O�tho�ax 7�adies �,w�i. , which has bee.n in �ciatenoe for 73 Year$,
` wiil be all - to rasztinue their spo�so- 'p,
. . � :: , , . . , .
.. , . w_. <
If Co�cil ; �vai is nat given, tl�e �t._ >�.a. ,RM�m�nian �doa�:Sadie�,°A�€3.]3�•r.y:w,il.l.be._ ,
forr�d t� ' .tinue t,heir spoa�sorsY�ip. .
• KT�lMIA7ME:. . . � _ tDplp_ - °
, , ., s: .
,,.: ,;>i�.Y. •< �=:; an � ,.�,<„
l�TORY/P�lFT8:
LEOAL�: '
' � .
� .�
. . ���.3yj
UIVISION OF LICENSE AND PERMIT A.DMINI TRATION DATE °� '«�"$� / o�"��'-'O b
INTERDF.PARTMF.NTAL REVIEW CHECKLIST Appn Processed/Received by
Lic Enf Aud
Applicant ��(C�h V Q,e�"Q Home Address ��� � ��ble�, Mtm �-�►,
i
Rus ine s s,Name �. � p n � Home Phone C.�$4 -'��1 J`�
t�hod.e (.A�d�es �4- X
Business Address Type of License(s) �d,'}�, C�4L S
Business Phone � � � 1Qy�,b(�r�,� �^ V��'� �t�
Public HQaring Date �� 8 License I.D. 4� � � ?7�
at 9:00 �.m. in the Council Chambers,
3rd floor City Hall and Courthouse State Tax I.D. 4� 1V � A.
llate Notice Sent • Dealer 4� � � �
to Applicant � / �
Federal Firearms 4� '�
Public Hearing
DATE INSP CTION
REVIEW VERFIED (C UTER) COMMENTS
A roved Not A roved
�
Bldg I & D �
��q�
Health Divn. �� � '
I
i
Fire Dept. � �
N�� I
Police Dept. ��'�I°�I 9Ig
License Divn. �
�
City Attorney �
1
Date Received:
Site Plan (J /4►
To Council Research
T� or 'Letter � � Date
from Landlord („ YLC�41��
. . � �����
� ' City of Saint Paul
`� , Deparcmenc of Financ and Hanagement Services
Division of License and Permit Registration z98-s�s�
INF'ORMATION RE UIRED WITH APPLICATION FOR P RMIT TO CONDUCT CHARITABLE GaMBLING GAME IN
SAINT PAUL . .•
.... µ...y�� ,..�.V'. a :., . . . . .. . _ . . �.. �. . ..
1. Full and complete name of.;organization which is applying for license
S . � oiy v2 o D o LHD ' vX L//�iP
Z. Address where games will be held / � Q�i� ST S>; j'��- SS//7
V mber Streec City Zip
3. Name of manager signing this applicati n who will conduct, operate and manage
Gambling Games � ,�/��,� � Date of Birth IL/ZG�z/
(a) Length of time manager has been me ber of applicant organization /y8/- �i�ES��
4. Address of Manager / s�/ �,� y �,ti� lsyµ�ry �T c. �,�*,veo �.E/� - ss/i�
Number Screet Cic� Zip
5. Day, dates, and hours this application is for N���y-`s 7•30 -- //;3� �iti.
6. Is the applicant or or�anization organ zed under the laws o� the State ci �IN? y�S'
7. Date of incorporation - 3 - 3
8. Date whea registered with the State oE Minnesoca $ - /3 - /9/3
9. How long has organization been in e:tf.s encs? ' 73 y,��s
10. How long has organization been ia esis eace in St. Paul? 7 3 y/��iLs
11. What is the purpose of the organ=zatio ? To /ftsisi iY.��oS� ��s:er�h' !�c-r7�'1�N �'�iJ/.�
P/t.v/�!i v a.y �L a „r� ss ,v•
I2. Officers of applicant organization '
�; •
Name /giv�v � vni 6 HRD ::Ya.me �'L o.pA TIy/z Z/U
SSf�o ' � S'Si�3
Address 2S 5 �ST �//07 /r�pcs� �r �Address 795�8 N�'�tivB.�/oca' ST. s/',n��c �n.�
.
Title P/�s/v�✓T DOB 3 6 L �''Ti-1e l�' ,�saR� DOB � �/y�/�
vame /+� YR �O�a�vi � 'Vame
SS/i 7 �
Address j ,y,,,o . �� �s�•�cuF �Y �:��dress
i
Title S6t1��'..T�C y DOB !� // 38 �i�tie DOB
13. Give names of officers, or any ot;er p rsons Jea �a�d �or s�r:�!ces to �ae or3ani=at:on.
Name -/ya�vF_ - Yame
Address �ddress
Title --�'-z
(,'.rzac� se�ar=te S�a•_ -.- .ac�'==_..•�_ ..�*-a:..
. � . � �����
„cached hereto is a list of names an addresses oi all members of the organiza[ic�n,
Str �7�3csr•�,�.r #/
in whose custody will organization's ecords be kept?
. , . .. . . . . ,
Name_.. .. _.. . , ... Address _ _
//// S/BtE Y �r6,�,m ��c /!/sy�,�,�
. 6. •�Persons.,who will' be conducting, assist ng in �conducting, `or operating the �ames:
Name. �E77,r Date of Birth
3��9�� �
Address /.�97 LAS�f' VC'NG• s �� ��
1 .� �c
Name of Spouse oT iG/Gy �,; S �.��r_'
Date of Birth —
Dates vhen such person will conduct, a sist, or operate _,Ev�cy �y,Er���, Cv6,�;..i�.��
;J, � _ .
:3y �i�.
Name ,c�L/Z �G ,s�� Date of Birth � 3 ,�� �
_�.:_...�..__.,
Address 2Z �,qST G��.�Sr,v� 5r ��. /zj ,,,,.�,�-so�9 SS//7
Nane ot Spouse ' ' ' Date of Birth _ z y ,3� �
, _ �,.
. Dates when sucz person *ri11 con�uct, as =st, or ope_ate �.�y �,�.c��,
y �v6r,.i�`
7; 3� �i� - //:3o P� - ". ,: _. . _.
17. Have ,�ou read and do ;rou thorougnly unde stand the provisions of all laws, ordina�.ct.s,
_,
and regulatior.s �averning che operat=on f Char:.table Gamb�ing games? y,�S
. �_.,4.,_
18. Atta�hed hereto oa the fa:� fur..ished bv the 'Cit� o� St. Paul is a Financial Repc��;.
whic:� �te�izes a11 recez�cs, e_t�ensas, a d d±soursemencs oi c�e aoplicant organ�r�: �
' as well as ai� erganizat'ons ::ho na=�e re e:�red =unds �or t:�e ore diag calen� r y�E:L(.�,.-..-�..
whfcl has beea s' �ed . { -• ,�;r�G�e,../c� ���-�-��0
-3- � P-z73_ed, and ve: t.ed Sy ��,,, ��
• �;a u__..�.
Ti��i�� �:NJvc. /yh /l�v�' 7�' � a�h' .�1!� .�i�C'. �/
i✓ ss i z
� :�da ess ' __., _
who is che c`��•;r ��y'. , �� „
, o� �he aeplicant Organizat��c�t�,.
Vame Of=�`
_c
19. Oper.ator ot pre�ises vhere ;ames �ril: ae .eLd':
Name a c: /p" v V/c:
B�siness Address /� �{/_ ,A/�,x- S , � Si_ ,�i�vc, ,�;�, y
Home Address _ 297 /�i�i�C��t /�L�,t.vF_ S�. ��`, . �-__._..
/Z1 �1rN
20. �►mount of rent paid by a�p::canc Or3ani�ac on rar cezt o� che E►all; specify amount� �
paid per 4-hour seas:on �� �*" '"
� SfF_ /�-�?l�c�l»�.6�.:,- ,z�Z. Ft2 /ar�:n�/-�c i�. /�i.;.'s�•.,,., �,�'i�,•� � I�iF_ l-�I�.,,c�s
, i r;���
l �r��s%7-� }�/kJ
. . � . ��y9
+The proceeds oc che gacaes w1I1 be di bursed after deducting prize layout costs and
operacing expenses for che following purposes and uses:
v�,C�'P oF P�iC/S o o� Gc i.✓G J� SS �t .�o
/�l'/-�MB S �/'� fiyv t
ZZ. Has the premises where the games are o be held been certified for occupanc}• by the
City oE Saint Paul? y,E S
23. Has your orgar.izat=on �iled �edera'_ � ra 990—T' � I� answer is yes, please atcacn
a copy with this applicac�on. Ic ans •a: is no, explain why: .
C / s c ,E v ,QE '_,�2. FiLE o o T EC s' �� �/aa� l'ic'� " s A�F_
- �. �x o z P� o ,� f/.�c ir cE' /F .1�,� �v o csi�ri»>v�F
�,qwFv� /�GiPPds� ii✓ nr.� s.r�,� y �s .�x�.c�_ r�j.� 990 is �v.r ��a��.r,�� F�.z A
�H�acii•
Any changes desired bl tae a?pl?cazc assoc+acion rna� be aade onl;r wich t::e consent o: the
City Counc{1. , "' �
�- �1� ,/� � ���-�-����'-��
,
�
Orgaa;zacion
' .G�i� �� ` V GL��Z l�._.
Date / � � .H �
� �fanage� in charge of game
v a _ � 3 �I L :n _ — � .. — � c� cn�
:� � t� •< 7 '� = - - _ � � o r.
n n rJ rr I �� S � ;v r. , — � G
f9 (D 't ^, _i j I . �A . — 10 3 � r`
f0 Z 7 . � �1 7 � .. n fD
= n 3 '< � - •.
3 G r- n -• r+ " O
_ _ _ ' T � r — � �
r— 3 77 C `< . �9 rr rr r0 i� rn
A 'J !: .� 71 � �G �
� � :, 7 � � .', F�''
� •• � �-I � � �1 � � R .f7. Ql N �
r* � '� � 'D rT E � �
� • � • � -. � � n •t fD N
, :e � 71 :A G � !+' � �G O
r ��� , ^ r+ 7C :a � C�
� j^' :7.�� � � f� JJ
� ::���:.�id- � � � 7 � � :.�
19 '11 ' �9 � � `�C v v v
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O r+ '- � � � :� N
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p'� fD n � -- , .. ro � r.
fp C': � � � �?,�� . -. I .� I .: �rt
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r„ A — � n T� '� � n �� io - � � I
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"'y �� '9 t r r� S �
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� ` �• Gharitable Gambling Control Board
� '�``�..`��'� Rm N-475 Griggs-Midway Bldg. For Board Use Only
' ' - 1821 University Ave. Paid Amt:
, - - St. Paul, MN 55104-3383 Check No. �.
_ :.....:'� (612) 642-0555
Date:
GAMBUNG LIC SE RENEWAL APPLICATION
LICENSE NUM'BER: R-42p78-t?02 /EFF.DA E: Ok/Ol/87 /AMOUNT OF FEE: Si0U.00
1.Applicant—Legal Name of Organization . 2,Street Address
ST �IARYS ROMANIAM ORTHl�OX IAQIES AUX " 854 i�oodla�idoe "
3. City, State,Zip 4.County 5. Business Phone
St Paul. MN S511i Ra�sev bi� 499-5b18
6. Name of Chief Executive Officer 7. Business Phone
n 'n d - +'t
8. Name of Treasurer or Person Who Accounts for Revenues 9. Business Phone
o L �1 - •
10. Name of Gambling Manager 11. Bond Number 12. Business Phone
=' �o L �f S
13. Name of Establishment Where Gambling Will Take Place 14.Counry 15. No.of Active Members
Ideal �all "t paul Ra+esev .3.5�z
16. Lessor Name 17. Monthly Rent:
Ideal Hall 3704 • i�s/,v�<.rr
18. If Bingo will be conducted with this license, please specity days nd times of Bingo.
Days Times Da Times Days Times
. :o : •�
� �
19. Has license ever.been: �yo � Revoked Date: ❑ Suspended Date: ❑ Denied Date:
20. Have internal controls been submitted previously? �'Yes ❑ No(If"No,"attach copy)
21. Has current lease been filed with the board? �Yes ❑ No(If"No,"attach copy)
22.Has current sketch been filed with the board? • . _.�r;__�!Yes;,, __O No jlf„NQ,".�ttach cqpy)_,._..._-_,j._ r � �
�.<� .,. :.�._
_. . _.. . ,
_ , T GAMBUNG SITE AUTHORIZATION
By my signature betow, local law enforcement o�cers or agents of t e Board are hereby authorized to enter upon the site,at any time, gambling is
being conducted,to observe the gambling arrd to enforce the law for any unauthorized game or practice. ,
BANK REC RDS AUTHORIZATION ,
By my signature below,the Board is hereby authorized to inspect th bank records of the General Gambling Bank Account whenever necessary to
fulfill requirements of current gambling rules and law.
OATH
I hereby declare that:
1. I have read this application and all information submitted to the B ard;
2: All information submitted is true,accurate and complete;
3. All other required information has been fully disclosed;
4. I am the chief executive officer of the.organization; -
5. I assume full responsibility for the fair and lawful operation of all a tivities to be conducted;
6. I will familiarize myself with the laws of the State of Minnesota res ecting gambling and rules of the board and agree, if licensed,to abide by those
laws and rules, including amendments thereto.
23.Official Legal Name of Organization Signature(Chief ecutive Officer) Date Title
�./ . ^� ��,I
.tiTi /fY.�.¢-t�i/'fi�,�"j'i1 , r'i/"�'f/i �
v1
J ' A / D V :'t/ q / , ^ O / �'� ��
ACKNOWLEDGEMENT QF TfCE BY LOCAI GOVERNIN(i BODY �
I hereby acknowledge receipt of a copy of this application. By ackno edging receipt, 1 admit having been served with notice that this application will
be reviewed by the Charitable Gambling Control Board and if approv by the Board,will become effective 30 days from the date of receipt(noted
below), unless a resolution of the local goveming body is passed whic specifically disallows such activiry and a copy of that resolution is received by
the Charitable Gambling Control Board within 30 days of the below n ed date.
24.City/Counry Name(Local Go rning Body) Township: If site is located within a township, please complete items 24
� '""' . � and 25:
Signature o Person Receiving Application: 25. Signature of Person Receiving Application
�.
; ` � -;, � ( ',4 �
Title v Da�e Fleceiv (this date begins 30 day�od) Title:
��� .�, • � � � � ,n✓ � -� e —K l�
Name.of Person Delivering Applibation to Local Governing Body: Township Name
� \ �!r ',/ - _ .
.t �
CG-00022-01 (5/8� hite Copy—Board Canary—Applicant Pink—Local Goveming Body
�
, �
°`��°" °"� �° °"�`°�°`�"° G R E E N S H E ET No. 0 0 0 8 2
Jeseph F: Carcliedi
� . , o�u�+r ow�cron rMran�on�srw+n
C�]tZStlri@ R02P�C N'�8 � �a wwr�oe�aa s�o�ron 3 cm c�wc
- NO' - tiotm - euooEr owcran " 2 COLII1C7.1 ReS�tC�l
• Finan�ce�&:�Mng�t. � - 298-5056 ono 1 «rr��r-°,� � .�. . .� . --- _ -
SUBJECT/DESCRIP71 N OF PROJ�CT/REGUEST:.
Renewel. application for a State of • 4LJGL.L.�.G7iJiC �.p�.g Il+�1� lX4lWJJ11g 1V,�.'�r
«
NC1I'g'ICATI� L1�TE: 2/22/88 L1A,TE: 3/8/88
RECOMMFNOA710NS:(ApW�e(A)a pq�(R)1 COUNCIL ESEARCN REPORT:
PLA1WN�q COMNq810N GVIL SERVICE CORMYSSION DA7E IN OA7E OUT ANM.YST - PqONE NO.
mNlflli COAAMIBSION - 190 625 SCf100L BQMO
STAPF CMARTER COAMA68810N PIETE AS IS AODL W W.MO�� RET9 TO CONiACT CONSTITUBf�
_ �fON ADDL WFO.* _FEED6�CK AOOm*
OISTRICf'COUtiCll � .
Of
&JPP�ORTS WFIICH COUNGL OBJEC7IVE7 . . .
uannnNO vaoe�r.�ss�u�,oPVOannarr Mmo.wnn.wn«�.wn«...wny►: - -
M3.- E11.2EI1 Vd1E31t0,- Qri b2�.f O� S�► �3 RC8[1�211.dI1..01'�]O�OQC.Ic'1[�1.ES A13X1113�'�Tr r�StS
� Coimcil appxmval of their ren�aal: appli tioa�. for a State-.of Mirmesota Charitable �,am��ng
� License.. A.Class "A' I�i.cesLSe a17.aws-. B�irigo and Pulltabs_ The sessions are held � .
: TuesdaY e�eYUngs: bets�en..the hr�urs of 7: 0 p.m- and 11:30 p.iu. at 1494 North Dale Street..
Prnceeds are..u.sed to assist tYye pari.sh . . . , ;
. . .
� .�:.. .-.� . -, ,_z,_�`:��,.,:::-.-� . . :.-.. :... �.,._-� . :--_:...:�::. - . .. . .�.;��-.... - . . . .. ...,�:��;w'. . . - __. : __. . ..
JIlSTFICATION•'(COWBMINNS.Adv�fueg�s.H�S�c " �- _ . _
. _ . .
.. ;: � . ...--• '_ = '. - " ..
- .... .. .�. .. _ _ �..,.'�s. . . .._ ,.+..�::. . _. ._ . . _ _ _.. _
AlT requi.red anplicatio�s ar�cl~fees have s�itted�; .�If CoimciT. a}�oval l� granted,
St.. Ma�.y's Raaariian Ortt�oda�x Ladies- ; tahich has: been in exist.ence for 73 years, �
� w.i:ll be allowe.d to c�mt.inue tt�ieir •g. . , .. , . _- _ �
�(�t�.and Ta W1wm►: ` --
If CALIIICII.. d�OV31 1S 2'�Ot g].V�I3, fil]+L' S� M32�7.�3 F�itdri'Lc'111 O�X Ix'3�d1P.S' AL�C1.11dt'y._Wil.l bE
forced ta disccmtinue their s�sorship. �
._.. __ .. . .
. . . . _ .. _.:. . ..
. ALTERNA7IVES: � . PROS _ - CONS ' .
•
. .--...._.-.:•�...-�..' •� _.�...,... -.:c' � . - . . . . . _ .._ . .._ � ...._ . .... .... . _. . . .
. . - . ��.•. . . .. . . .. .._ . . . .
. . .. . - - � - .,:�:.. . . �- � . . .
MISTONY/PRECEDENTS: � ,
� �....� � ' : � . - �
. . _ . : .1
. . _ti . � _.
�u�issuES: � .
" ' � Ci y oE Saint Paul ��,3�9
_ ' D�parcmenc oE F nance and 4a�agemenc Services
�, Division oE Lic nse and Yermie adainistration
UNIFOtU1 CHARITA LE C/1l18LINC FItiANCIAL REPORT
_ _. Date 2�3�5 u
' .` 1. Nme of Organizatioa ST. � o p o,p�x � C X/u�I�ty
� .. . 't . .. . ..._..
2. Address vhere Charitable• Cawbling is conducted _lSl.y� ,y ���s S!- ,sll.�I�vL /lIN%
�. Reporc: Eor period covering J � y I 19 87 through /�,EC,Gyr�a�;¢;/Lg�1
4. Tocal number of days played Z
S. Croas Teceipca for above paciod s Z2(� 3 0
�
6. Ccoas priza payou�s for above peri J ; /7 9� D/Z
7. Nec recelpts - 11n� 5 minua line 6 s �7�6�o�
9• Expenses Lneu�reJ ln conducting ao operacing gaae:
A. Cross vages p�id. Attaeh work r list vith
names, address and gro�s wgea set A77Atisr�!»�T �3 S �o,S60
8. Renc for SZ v�eka . S 879s
C. License fee . � /D 0
D. Insu�ance �
E. Boed
. ; /no
F. Dlshonored ehacks noc rscov�red ; ��SZ
G. Employara F.I.C.A. • _ • _
� H, Sales Tax �
N�A
I, riinn. U.C. Tax � ; _
� J. Federal U.C. Tax ; S _.
K. Hiscellaneous fxpenses. Idanci the a�unt
artd ta vhom paid.
I. /�✓�t 7�1't+'S �F Su.qyt/ES ; /SS Z
ADvF,V7S/�✓4 s�
2. ,�x��s.� r�x—P.«,,,a.r ; �/9/�
c..a�...,,.a -
Acw�� Iv j 3zs .
3. n a- DA!!ec cars�cl. i .�oa .
IRS w�►t�F,f/tib 771X Z Q� . �
4. /a9. t�rlu.�s N�f •�y�r lH G.jj. j 29 G 9
°r�i�`'a , y Z ,
9. Tocal E:cpe�ses TOTAL f 2$��jL9
l0. Net Ineoaa - line ) minus line 9 �� j �8 �la q
r �
.11. Checkbook Salance beginning of perio S j 2 2/
12. Total oE line !0 and !t S L Z.c 90
13. Tota! contributtons :rom liae lJ S _��f ja0
14, Checkbook balance end of reporting pe 1od - ti
line 12 le�s line (3 � S 7]j0
l5. Speeify uae made of amounc on line 1J
/9'CL f�r�vpt E f On.�!2/B _s� /,f ST I�1/� d I y4'+�v//Ji✓
_ �iQ171aDo�lr ��s ,�� 7a SKrr'L oD cceT �✓G � Sri1/l�Jvc�f Fi�-
�s �h " !RS_
r.oMr�.�:r� n h ttEVCRSE Si«E
� , lb: D�..Surssnencs itom aaount La line t2 ����
. .
. . � Nama Sr /y J �nrilrr C v Name s'/��f �
�oN7
Addreas 4�S w000B�p/ayF_ T, s A�c. Address
Dace Aac'd ��= 87 _ Date Rae'd S�3o�$f S�''�-`
. .-Purpos� f••y. ��l�iw✓�j c �'�.� Purpos� 9/3./B7
` ` ' Signacure ' �usli �6.��B�es . . .:. Signacure �
�/Soo
.;..s;, _ ,. ;;:ot ,R�aipia�c, , . ol RaciQienc� �.� - -�
. . '� .: . .. . , . MOYAC � � OJ ..._. . �: . . .. � A/04RC �OO
Name .s c s rvc Nase s/lfyj� S7ntf_
Addr�ss Addreas
Dacs Ree'd Z�2y��97 Date Rec'd (��jo�S7 ���3°�3•7
Purpose Purpoaa .$/Suo
5lgnacura Signscare
of Racipien . oE &acipient,� � ��, .�/
• Amounc � �a � . , Aowunt � Do�
Name S'/)y.u. � Naoe S/h'+lF_ s'wi++F_
Addcess Addreae
Daca ltec'd 3��/�47 Date Rec'd 7�2$�$7 ///27��17
�/S�u
Purpoea Purpoae _
Signature Signatura ,��
oE Rseipiant ��i?.�� oE Reeipienc��%X_„��A� � "� �
Amount 7 0 o Amount �So 0
' Name S/p"►f Name S/�ir S�E
Addrass Address • /L/3/�t?;'
Dact Ret'd y��30�s7 �'Date Rec'd 8�3/��7 '
�z,s-�,,
' Purpoae �Purpoae
� Signature Signacuce r(�, n�����lf�i�� �+
oE Recipieat af Recipienc"� ��
Amounc 8c� Amc„nc 1�isoo
17. Total Oinbursemsrtts
THIS REPORT iiUST BE FILLED•IN CO�LETII.Y TO UALIFI APPLICATION FOR CHARITASLE GalBLINC
LICENSE.
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