Form GCVS-2 "Verified Statement of Raffle Operations With Net Profits Less Than $30,000" - New York

What Is Form GCVS-2?

This is a legal form that was released by the New York State Gaming Commission - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2014;
  • The latest edition provided by the New York State Gaming Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form GCVS-2 by clicking the link below or browse more documents and templates provided by the New York State Gaming Commission.

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Download Form GCVS-2 "Verified Statement of Raffle Operations With Net Profits Less Than $30,000" - New York

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Division of Charitable Gaming
GCVS-2 Verified Statement of Raffle Operations
To Report Net Profits Less Than $30,000
For The Calendar Year:________
th
Instructions: Prepare report in triplicate. Due January 30
of the year following the conduct of a raffle
occasion. Send original to clerk of your municipality, one copy to NYS Gaming Commission and retain one
copy for your files.
Name of Organization: ____________________________________________________________________
Games of Chance Identification Number: ____________________________________________________
Street Address: ___________________________________________________________________________
City, Town or Village
: ____________________________
Zip Code: _____________
(circle one)
Phone Number: ___________________________
Date(s) of Raffle Drawing(s)
A. RECEIPTS
If there is more than one drawing, attach schedules detailing origin of figures for Sections A and B
(
)
1. Tickets
a. Number of tickets printed: _________________________________
b. Number of tickets sold: ___________________________________
c. Number of tickets unsold: __________________________________
d. Price of each ticket: ______________________________________
e. Ticket receipts (line 1b times line 1d): ________________________
2. Other Receipts: ____________________________________________
3. Total Receipts
: ________________________
(Add lines A1e and A2)
www.gaming.ny.gov
Page 1 of 2
GCVS-2 (Rev. 3/2014)
Division of Charitable Gaming
GCVS-2 Verified Statement of Raffle Operations
To Report Net Profits Less Than $30,000
For The Calendar Year:________
th
Instructions: Prepare report in triplicate. Due January 30
of the year following the conduct of a raffle
occasion. Send original to clerk of your municipality, one copy to NYS Gaming Commission and retain one
copy for your files.
Name of Organization: ____________________________________________________________________
Games of Chance Identification Number: ____________________________________________________
Street Address: ___________________________________________________________________________
City, Town or Village
: ____________________________
Zip Code: _____________
(circle one)
Phone Number: ___________________________
Date(s) of Raffle Drawing(s)
A. RECEIPTS
If there is more than one drawing, attach schedules detailing origin of figures for Sections A and B
(
)
1. Tickets
a. Number of tickets printed: _________________________________
b. Number of tickets sold: ___________________________________
c. Number of tickets unsold: __________________________________
d. Price of each ticket: ______________________________________
e. Ticket receipts (line 1b times line 1d): ________________________
2. Other Receipts: ____________________________________________
3. Total Receipts
: ________________________
(Add lines A1e and A2)
www.gaming.ny.gov
Page 1 of 2
GCVS-2 (Rev. 3/2014)
B. EXPENDITURES
(Only payments directly related to the conduct of the raffle. Attach schedule if additional space
is required.)
Describe Expenditure
Payee
Check No.
Amount
1. Total Value of Prizes
:
______________________
____________
____________
(Part E)
2. Tickets:
______________________
____________
____________
3. Raffle Equipment & Supplies:
______________________
____________
____________
4. Services:
______________________
____________
____________
5. Rent:
______________________
____________
____________
6. Other Expenses:
______________________
____________
____________
______________________
______________________ _____________
____________
______________________
______________________ _____________
____________
______________________
______________________ _____________
____________
7. Total Expenditures
: _________________________
(Add lines B1 through B7)
C. NET PROFIT OR (LOSS)
1. Net Profit or (Loss) (
: ____________________________
line A3 less line B7)
STOP: Is the figure on line C1 greater than $30,000.00? If so, then you will need to obtain a raffle
license from your municipal clerk and file Form GC-7R. If the figure on line C1 is less than or equal
to $30,000.00 this is the correct statement to file.
D. DISPOSITION OF AND ACCOUNTING FOR NET PROCEEDS
1. Unexpended balance of net proceeds shown on last report: ______________________________
2. Net Profit or (Loss) from this occasion
:
____________________________________
(line C1)
3. Interest earned on net proceeds on deposit in interest bearing account(s): ____________________
4. Other deposits into or adjustments in Special Games of Chance Account: ___________________
Explanation: ___________________________________________________________________
5. Total Net proceeds
: _______________________________________
(Add lines D1 through D5)
www.gaming.ny.gov
Page 2 of 4
GCVS-2 (Rev. 3/2014)
Disbursements of Net Proceeds since last report: (Attach schedule if more space is needed)
Date
Check No.
Description of Disbursements
Name & Address of Payee
Amount
______
________
_______________________
______________________
________
______
________
_______________________
______________________
________
______
________
_______________________
______________________
________
______
________
_______________________
______________________
________
______
________
_______________________
______________________
________
6. Total Disbursements: _______________________
7. Unexpended balance of net proceeds
: ________________________
(line D6 less line D7)
E. SCHEDULE OF PRIZES
(Cash or Fair Market Value of Merchandise Prize(s))
Description of Prizes
Value
__________________________________________________
_________________________
__________________________________________________
_________________________
__________________________________________________
_________________________
__________________________________________________
_________________________
Total Value of Prizes (
_________________________
Report on line B1):
F. SCHEDULE OF DONATED PRIZES
(Cash or Fair Market Value of Merchandise Prize(s))
Description of Prizes (Donated Only)
Value
__________________________________________________
_________________________
__________________________________________________
_________________________
__________________________________________________
_________________________
__________________________________________________
_________________________
Total Value of Donated Prizes
_________________________
www.gaming.ny.gov
Page 3 of 4
GCVS-2 (Rev. 3/2014)
G. TOTAL VALUE OF PRIZES
_________________________
(Total from Part E plus Part F):
H. DECLARATION: (
All three sections must be signed. Unsigned reports will be returned):
I swear or affirm that the information and statements contained herein have been examined by me and
are true, accurate and complete
.
Head of Organization:
___________________________________________________ ___________________
Signature
Date
_________________________________________________ ______________________________________________
Print Name
Print Title
__________________________________________________________________ (______)____________________
Home Address, City and Zip Code
Phone Number
____________________________________________________
Email Address
Preparer of Report:
___________________________________________________ ___________________
Signature
Date
_________________________________________________ ______________________________________________
Print Name
Print Title
__________________________________________________________________ (______)____________________
Home Address, City and Zip Code
Phone Number
____________________________________________________
Email Address
Member In Charge:
___________________________________________________ ____________________
Signature
Date
_________________________________________________ ______________________________________________
Print Name
Print Title
__________________________________________________________________ (______)____________________
Home Address, City and Zip Code
Phone Number
____________________________________________________
Email Address
www.gaming.ny.gov
Page 4 of 4
GCVS-2 (Rev. 3/2014)
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