202490 10/11/2011 CITY OF CARMEL, INDIANA VENDOR: 00351917 Page 1 of 1
ONE CIVIC SQUARE CARMEL FIRE DEPARTMENT AUXILIARY
i CHECK AMOUNT: $450.00
CARMEL, INDIANA 46032 C!0 CARMEL FIRE DEPT
CARMEL IN 46032 CHECK NUMBER: 202490
CHECK DATE: 10/11/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1160 4359003 50.00 PERMIT REIMBURSEMENT
1160 4359003 5424 400.00 HOLIDAY ON THE SQUARE
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CARMEL, IN 46032
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PAY D T OR OR D ER OF HE DATE
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CG -RAF, APPLICATION FOR RAFFLE LICENSE For official use only
License Fee Paid_
State Form 45384 (8216 -11) Date Received
Approved by State Board of Accounts, 2011 Reviewed B
INDIANA GAMING COMMISSION Date Reviewed
Date Keyed
INSTRUCTIONS: Please enclose license fee. Allow forty-five (45) business days to process.
1. Organization name (please type or print)
Carmel Fire Auxiliary Inc.
2. Address of principal office (number and street, city, state, and ZIP code) P.O. Box Number (if applicable)
Two Civic Square, Carmel, IN 46032
3. Organization daytime telephone number Please include extension number 4. Organization fax number
317) 571 -2600 1 1 317) 571 -2615
5. Federal Identification number (FID) 6. Email address
35 2122650 1 dpattyn @carmel.in.gov
7. Contact person's name and title Contact person's daytime telephone number Please include extension number
Dawn Pattyn [317) 571 -2603
8. On what date and during what hours will your event be conducted? (A.M. establishes the midnight hour, P.M. establishes the noon hour.)
Date 11 -19 -2011 Hours 4:30 P M to 8:00 P M
9. Address of the facility where the gaming event will be conducted (number and street)
Two Civic Square and on adjacent Civic Square gounds
City State ZIP code County
Carmel IN 46032 Hamilton
4FACILITbY/TANGYBLE" PERSONAL PROPER'L'Y INFORMATION
Attach
sheets necessary to su_ pply all information foreach line.
J 10. Does your organization own lease (rent) Y or use a donated facility where the licensed event will be conducted? (Check one)
If leased (rented) or donated, enter name and address of lessor or donor and attach a copy of your signed lease or donation agreement.
Name of lessor /donor (Full legal name) Address (number and street)
City State ZIP code County Daytime telephone number
11. is any tangible personal property (e.g. tables, chairs) or gaming equipment/device being leased or donated to you for this event? [I Yes No
If you answered Yes, list the name and address of the lessor or donor. Attach a signed copy of the lease or donation agreement.
Note: Gaming equipment/device must originate from a licensed distributor or manufacturer.
Name Address (number and street) City State ZIP code
iVlanufacturer and JA
Attach adilifional sheets if neces`sary
I
List the distributor(s) from whom you intend to purchase licensed supplies.
Name Address (number and street) City State ZIP Code Items
Not Applicable
13. Does your organization own gaming equipment or devices? No
If so, list the distributor /manufacturer's name, date of purchase, purchase price, and type of equipment purchased.
Name of Distributor/Manufacturer Date of Purchase Purchase Price Type of Equipment/Device
Page 1 of 4
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i Please list at least three (3) operators who will supervise, manage, and be responsible for the operation and conduct of the gaming event.
I Driver's License or Date of Birth Daytime Telephone Date Joined Check all
Full Legal Name Home Address Organization appropriate
(number street, city, state, ZIP code) State I.D. (month, ay, Number (month, day. boxes
year)
i
Bartender
j Dawn Elizabeth Pattyn 141 Sherman Drive, Carmel, IN 46032 Member m
8919-93-7306 03 -28-63 317) 571 -2603 02 -14 -05
Bartender
Jean Marie Junket 7901 Windhill Drive, Indianapolis, IN Member m
46256 8915 -16 -3476 03 -12-60 317 571 -2616 09 -21 -96
Bartender [3 Nancy Sue Heck 1326 Cool Creek Drive, Carmel, IN Member m
46033 8924-66 -7766 12 -07 -58 (317 571 -5393 03 -14
15. Please list the name from above of the principal operator who has overall responsibility for the operation and control of this charity gaming event.
X Name Daytime telephone number
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Attach addltronaf „sheets if
16. List all individuals (excludin operator information above) who will assist and work in the o eration of the licensed event.
Full Legal Name Home Address Driver's License or Date of Birth Daytime Telephone Date Joined Check all
y Organization appropriate
(number street, city, state, ZIP code) State I.D. month, day, Number (month, day, boxes
year) year)
Bartender E3 Employee [3 Mary Ellen Gates Osborne 9875 Lakewood Drive, Indianapolis, IN 8943-56-1923 07 -22-60 317) 590 -7522 N/A Member C3
46280 Bartender
Employee
Deborah J Miles 7692 Creekside Drive, Fishers, IN 8940-23 -6157 09 -02 -55 (317)694-3153 N/A Member
46028 Bartender
Employee
N/A Member
Bartender
Employee
Member
17. Have any operators/ No ers listed
ou answered yes, attach a list including each n0- e, type and date of conviction, t and jurisdiction/court
in any on lines 14 and 16, or on any additional sheets been convicted of a felony
jurisdiction. ❑Yes Y 7 yr
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t.. ���}#s r, kt .h.x�a., °£t,'�,sk4,„sz.•,...�.
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t� Yoilunteer T>tcket�i ent Information t a-
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i4ttach addrtionat sheets,ifnecessaryp�s��
18. Will the organization utilize Volunteer Ticket Agents ("VTA to sell tickets for the event? Q] Yes No
If yes, please provide the name, address, telephone, and name of the General Manager of each retail establishment whose
employees will serve as volunteer ticket agents. A VTA may only sell tickets.
Name of the General :Telepho:neN b er of the General
Name of Retail Establishment Address of Retail Establishment Manager anager
(number and street, city, state, ZIP code)
Carmel Fire Department Two Civic Square, Carmel, IN 46032 Fire Chief Keith Smith (317) 571 -2600
Page 2 of 4
CG -RAF
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rw y �Gross RetailF Sales fi 7 r; r
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Y`:ty
'Will you conduct any type of retail sales during the licensed event (e.g. concessions, daubers, snacks, etc.)? (Check one) E] Yes* No
f "Yes" complete the following information. If the seller is required to have a Retail Merchant Certificate, enter that number in the box provided.
Name of organization offering the sales Retail Merchant Certificate Number
1: Which of the following will your organization be receiving? (Check one)
All of the retail sales income A flat fee retail sales payment
A percentage of the retail sales income Other (explain)
�M� Add><honal�Achvrt►es Author><zed�. z� u
1. Will your organization sell pull tabs, punchboards, and/or tip boards? _Yes No
Will your organization conduct a door prize drawing at this event? _Yes V No
(Limitation on door prize drawings at all events is $1,500 and cannot be increased.)
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2. Where will the charity gaming financial records be maintained?
Address (number and street)
Two Civic Square
City State ZIP code
Carmel I IN 1 46032
3. Name, address, and telephone number of the person maintaining these records.
Name
Jean Junker
Address (number and street)
Two Civic Square
City State ZIP code Daytime telephone number
Carmel IN 1 46032 (317) 571 -2616
1. List the organization's separate and segregated charity gaming checking account information.
ameofbank
PNC
ddress (number and street)
21 North Range Line Road
i State ZIP code
Carmel IN 46032
ame of separate and segregated Charity Gaming checking account Account number
:FD Auxiliary (CAP) 1 698447169
ense�Fee�Information
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k�,'��e'�.�� �`:,�,ad� �i�,u.�'� �";R+�.�.:� 4w1.�,3.'.�,J L�r�s'�.r;^..:sw�7 �'i�jv :sn.f .'�sa:.a ,.d...o. ,�m'.�'�.t
5. The license fee for your f "t Raffle License is $50.00. All su Sequent license fees will be based on the adjusted gross receipts from the last event of
to same type. You will fin this license fee amount on pag�item #4 of the Indiana Charity Gaming Single Event Financial Report, Form CG -9. The
e should be paid by check d awn from your separate a d segregated Charity Gaming checking account. Make your check payable to: Indiana
:aming Commission. Do not d cash.
lotice: Have you held a Raffle License within the last three (3) years? E] Yes No
[yes, your license fee is based on the gross receipts of your last Raffle event. If no, your initial license fee is $50.00.
Page 3 of 4
CG -RAF
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1 We certify under penalty of perjury that there are no misrepresentations or falsifications m the information stated. We understand false or misleading
,tatements will cause rejection of this application or revocation of future license(s).
a X03 1 0/51 20 1
Signature of Presiding Officer Print name Title Daytime telephone number Date oWA, day, year)
t f J� J '�C_ V., ru k i J" ILI
Print name Daytime telephone number Date (month. day, year)
Sec ry
Send this application and appropriate fee to:
Indiana Gaming Commission
Charity Gaming Division
101 W. Washington St., East Tower, Suite 1600
Indianapolis, IN 46204
Phone: (317) 232 -4646
Page 4 of 4
CG -RAF
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
10/05/11 Application $50.00
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6
20
Clerk- Treasurer
VOUCHER NO. WARRANT N
ALLOWED 20
CFD Ladies Auxilary
IN SUM OF
Two Civic Square
Carmel, IN 46032
$50.00
ON ACCOUNT OF APPROPRIATION FOR
Mayor's Office
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1160 Application 43- 590.03 $50.00 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
Sunday, October 09, 2011
M or
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
aai®nui
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o� I I' I l ��1•
ge
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
09/27/11 Invoice $400.00
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
CFD Ladies Auxilary
IN SUM OF
Two Civic Square
Carmel, IN 46032
$400.00
ON ACCOUNT OF APPROPRIATION FOR
Mayor's Office
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Invoice 43- 590.03 $400.00 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
Sunday, October 09, 2011
Mayor
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund