DEPARTMENT OF HEALTH AND HUMAN SERVICES Licensure and Regulatory Services 255 Rockville Pike, 1st Floor, Ste 100 Rockville, Maryland 20850-2368 240-777-3986 Fax 240-777-3088 www.montgomerycountymd.gov/licensure
RAFFLE PERMIT APPLICATION Application is hereby made for a Raffle Permit in Montgomery County, Maryland
TODAY’S DATE____________________
Name of Organization Conducting Raffle: ____________________________________________________________
Mailing Address of Organization: ______________________________________________________________________ Street Number and Street Name
________________________________________________________________ Telephone #: __________________ City State Zip Code Include Area Code
Location of Raffle: ______________________________________________________________________________ Street Number and Street Name
____________________________________________________________________________________________ City State Zip Code
Starting Date of Raffle:__________________________ Ending Date of Raffle:___________________________
Item(s) to be Raffled:__________________________________________________________________________
Number of Tickets to be Sold:____________________________ Cost of Each Ticket:______________________
Name of Organization Officer:__________________________________________Title:_____________________
Address of Organization Officer:________________________________________________________________ Street Number and Street Name
___________________________________________________________Telephone Number:_________________ City State Zip Code Include Area Code
Fax Telephone:__________________________Email Address:____________________________________________ Include Area Code
Person(s) actually conducting raffle:____________________________________________________________________ Name and address(Must be Montgomery County resident(s) and member(s) of the organization)
Two Page Application – Be sure to complete both pages and submit all attachments.
I hereby certify that the above information is accurate and complete:
Signature of Owner or Agent:_________________________________________________________________
Printed Name and Title of Above Signatury:_____________________________________________________
Payment Method:Check Money Order Visa Mastercard ________CV/CVC (3 digit security code)
Credit Card payment: Fax to 240-777-4531 (Confidental fax line)
Cardholder’s Name:________________________ Cardholder’s Signature:____________________________ Credit Card No:______________________________ Exp. Date:___________ Amount:_________________ I agree to pay the indicated total amount according to card issuer agreement. OFFICE USE ONLY: Receipt Number: ______________ Date Issued: _______________ Amount Paid: _________________ Date Expires: ______________ Check No: _________ Expires: ___________ Staff Initials:_________
Raffle Permit Application Page 2
I, the undersigned:
a. Having read Article 27, Section 255B, the organization I represent is eligible to conduct a Raffle under said law. b. No agreement exists for the diversion of any proceeds from the Raffle to any other person, or legal or business entity. c. No person or legal or business entity shall receive any portion of the proceeds of the raffle except in furtherance of the purpose of the non-profit organization. d. I verify that the person conducting this raffle is a member of this organization and a resident of Montgomery County, Maryland.
Signature of Organization Officer Responsible:_____________________________________________
Title of Organization Officer Responsible:_________________________________________________
Please have application notarized below.
State of Maryland
Montgomery County, to wit:
This certifies that on this ____________ day of ________________________, ________, before the subscriber, a Notary Public in and for the State and County aforesaid personally appeared the applicant(s) named in the aforegoing application and made oath in due form of law that the statements made therein are true to the best of his/her knowledge and belief.
Witness my hand and official seal.
My commission expires;_______________________________
The following attachments must accompany the application
Submit a brief statement of purpose and objective of your organization and the purpose for which proceeds will be used, signed by the applicant(s).
Submit the names and addresses of all organization officers and directors.
Submit a copy of the letter your organization received from the Internal Revenue Service establishing your group as a non-profit organization exempt from federal income tax under section 501 (c) (3), (4), (7), or (10) of the Internal Revenue Code.
A copy of the Disclosure Statement filed with the Secretary of State of Maryland must be submitted when the raffle involves real property (real estate).
