SOUTH CAROLINA SECRETARY OF STATE PUBLIC CHARITIES DIVISION ANNUAL RAFFLE FINANCIAL REPORT Filing Instructions The annual raffle financial report must be filed no later than the 15th day of the 5th month, or 4 ½ months, after the end of the charitable organization's fiscal year. For example, if the organization's fiscal year runs from January 1st to December 31st, this report is due on May 15th. If the organization's fiscal year runs from July 1st to June 30th, this report is due on November 15th. Raffles that are exempt under S.C. Code of Laws §33-57-120(B)(2) do not need to be included in this report. We do not accept this filing by fax or email; please mail this form to South Carolina Secretary of State, Attn: Division of Public Charities, 1205 Pendleton St., Suite 525, Columbia, SC 29201. Please type or print clearly. You may attach additional pages as necessary. Please contact our office with any questions at 803-734-1790 or charities@sos.sc.gov. This raffle report covers the fiscal year beginning _________, 20___, and ending _________, 20___. Check if applicable: Initial Filing Amended Filing Change in Fiscal Year EIN: ____-_____________ Organization Name: DBA: Mailing Address: Raffle Registration ID: Email Address: _____________________________ Phone Number: Brief Description of Organization's Charitable Purpose: Total Number of Nonexempt Raffles Conducted During the Fiscal Year Covered by this Report: Please complete the information in Parts I through VI for each nonexempt raffle conducted during the fiscal year covered by this report. You may attach additional pages as necessary. For example, if your organization conducted 4 raffles during the prior fiscal year, you will need to copy or print 4 copies of pages 2-4 of this form and complete Parts I through VI for each separate raffle. Annual Raffled Financial Report Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Part I-- General Raffle Information Date of Raffle Drawing: Number of Raffle Tickets Sold: Was this a fifty-fifty raffle? Part II-- Raffle Prizes List all prizes offered and given in the raffle, including cash prizes; the estimated of each prize; whether the prize was donated to or purchased by your organization; and the total estimated value of all prizes. You may attach a separate sheet or additional pages as necessary. List All Cash Prizes Below Yes Cost of Each Raffle Ticket: No 1. Total Value of All Cash Prizes Offered or Given List All Noncash Prizes That Were Donated to the Organization Estimated Value 2. Total Value of All Donated Noncash Prizes Offered or Given List All Noncash Prizes That Were Purchased by the Organization Value/Purchase Price 3. Total Value of All Purchased Noncash Prizes Offered or Given 4. Total Value of All Prizes (add lines 1, 2 & 3) Annual Raffled Financial Report Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Part III-- Gross Receipts and Adjusted Gross Receipts List the amount of gross receipts from the raffle, the total amount of cash prizes offered or given; the total amount your organization paid to purchase noncash prizes offered or given; and the amount of adjusted gross receipts. "Gross receipts" means all funds collected or received from conducting the raffle. "Adjusted gross receipts" means gross receipts less all cash prizes and the amount paid for any noncash prizes purchased by your organization. 5. 6. 7. 8. Amount of Gross Receipts Amount of Cash Prizes (amount from line 1) Amount Spent by Charity on Noncash Prizes (amount from line 3) Amount of Adjusted Gross Receipts (subtract lines 6 & 7 from line 5) Part IV-- Itemized List of Expenses and Expenditures List all expenses or expenditures incurred by your organization in conducting the raffle, and the person, company, or governmental entity to whom the expense was paid or the expenditure will be made. You may attach a separate sheet or additional pages as necessary. Examples of allowable expenses for raffles include advertising; reasonable office supplies and copying; food and beverages for attendees and volunteers for raffle event; entertainment-related costs; bookkeeping, accounting and legal services; costs for permits, fees, or taxes paid to local or state government; and raffle prizes. For a comprehensive list of allowable expenses, please see S.C. Code of Laws §33-57-150. Type of Expense/ Expenditure Person, Company, or Governmental Entity to Whom Expense Was Paid or Expenditure Will Be Made Amount of Expense/ Expenditure 9. Total Amount of All Expenses and Expenditures for Raffle Annual Raffled Financial Report Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Part V-- Net Receipts List the total amount of net receipts from the raffle, and the use or uses to which the net receipts have been or will be applied. "Net receipts" means the adjusted gross receipts from the raffle (see Part III, line 8 of this form) less all expenses, charges, fees, and deductions that are authorized by law. 10. Amount of Adjusted Gross Receipts (amount from line 8) 11. Amount of Authorized Expenses/Expenditures (amount from line 9) 12. Amount of Net Receipts (subtract line 11 from line 10) Part VI-- Use of Net Receipts Provide a brief description of the use or purpose to which the net receipts have been or will be applied, and the amount of the net receipts dedicated to each use or purpose. The total amount of expenditures from the net receipts should be listed in line 13. Attach a separate sheet or additional pages as necessary. Use or Purpose to Which Net Receipts Were or Will Be Applied Amount Dedicated to Use or Purpose 13. Total Expenditures from Net Receipts (line 13 should match line 12) Part VII--Certification This form must be certified as true and signed under penalty or perjury, pursuant to S.C. Code of Laws §33-57150(C), by the Chief Executive Officer and the Chief Financial Officer of the charitable organization. If one person serves as both CEO and CFO for the charitable organization, he or she should sign in both places below. We hereby certify, under penalty of perjury, that the information furnished in this annual raffle financial report is true and correct to the best of our knowledge and belief. CEO Name : Signature: Date: CFO Name : Signature: Date: Annual Raffled Financial Report Page 4 American LegalNet, Inc. www.FormsWorkFlow.com