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Arizona Form Affidavit Bingo 830 This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo If any information is blank or incorrect, the affidavit will be returned to you All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary This information may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404, Licensee's Name Sun Lakes Rotary Club Affronts Name itVENUE USE ONLY. DO NOT MARK IN THIS AREA. DeAnne Rasmussen phi Work Phone No (With area code) If licensee is a qualified organization, the following section Is required: Member? Date Joined Organization Yes DNo 19/11941999 [Officers? Officer Title Yes CI No Sargent at Arms Do you have an affidavit on file for any other licensee? DYes _51,No If 'Yes", list license number(s). El Position: Proceeds Coordinator the above-named affiant, under penalty of perjury, upon AFFIANT S NAME oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affront Date 0 Position: Manager I, • the above-named affiant, under penalty of perjury, upon oath, AFFLANT S NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affront Date ADOR 10327 (12/18) Affiant s Name (as shown on page 1) LDeAnne Rasmussen 0 Position: Supervisor , the above-named affiant, under penalty of perjury, upon oath, A IAN IS FIAj,IE depose and say that I will be continuously present on the premises during all bingo games and until all associated activities have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant DeAnne Rasmussen , the above-named affiant, under penalty of perjury, upon oath, AFFIAIIT S NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant 5/21/2019 Date Review Form and Sign Before Submitting Bingo Customer Service Center To avoid processing delays and errors, take a few moments to make sure you have entered all of the Locations required information and verify that it is accurate. 8:00 a.m. - 5:00 p.m. Affiant's Signature Monday through Friday Sign and date the form. (Except legal Arizona state holidays) The form can be: Phoenix Office Emailed to: 1600 West Monroe bingo@azdorgov Phoenix, AZ 85007 Faxed to: 602-716-7973 Bingo Customer Service Telephone Mailed to: Bingo Tax Unit Number PO Box 29019 Phoenix, AZ 85038-9019 (602) 716-7801 ADOR 10327 (12118) Page 2 Ariidha Form Affidavit Bingo 830 This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404. Licensee's Name License Number sJ Z-41‹ Ot5 /02 -14 /C'Y a L Affiejliks Name —> a VENUE USE ONLY. DO NOT MARK IN THIS AREA. 0/ 0 0 Date of Birth 1 C State II Work Phone No. (with area code) If licensee is a qualified organization, the following section is required: Member? Date Joined Organization EZ1 Yes I No /L9 I / I a. 0 /CP Officers? Officer Title " Yes SNo 7 4 - e i-e. e-r- Do you have an affidavit on file for any other licensee? 0 Yes 0 No If "Yes", list license number(s): D Position: Proceeds Coordinator , the above-named affiant, under penalty of perjury, upon AFFIANT'S NAME oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date 0 Position: Manager , the above-named affiant, under penalty of perjury, upon oath, AFFIANT S NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date ADOR 10327 (12/18) Affiant's Name (as shown_Qg page 1) Bingo Affidavit ki Position: Supervisor I, 13 ', ny CXL ) , the above-named affiant, under penalty of perjury, upon oath, AFFIANT'S NAME depose and say that I will be continuously present on the premises during all bingo games and until all associated activities have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. £4 > CL‘f Signature of Affi — Date Position: Assistant , the above-named affiant, under penalty of perjury, upon oath, AFFIANT'S NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date Review Form and Sign Before Submitting Bingo Customer Service Center To avoid processing delays and errors, take a few moments to make sure you have entered all of the Locations required information and verify that it is accurate. 8:00 a.m. - 5:00 p.m. Affiant's Signature Monday through Friday Sign and date the form. (Except legal Arizona state holidays) The form can be: Phoenix Office 1600 West Monroe Emailed to: bingo@azdor.gov Phoenix, AZ 85007 Faxed to: 602-716-7973 Bingo Customer Service Telephone Mailed to: Bingo Tax Unit Number PO Box 29019 Phoenix, AZ 85038-9019 (602) 716-7801 ADOR 10327 (12/18) Page 2 Arizona Form Affidavit Bingo 830 This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404. Licensees Name License Number Spr 1,-411(65' Affiant's Name 0 ifENUE USE ONLY. DO NOT MARK IN THIS AREA. •P iV A i.-_D ,_66.--r/ P,/ Soci Add Ci 21 If licensee is a qualified organization, the following section is required: Member? Date Joined Organization rit Yes 0 No I) I 1i Officers? Officer Title aYes El No Do you have an affidavit on file for any other licensee? Yes .121, No If "Yes", list license number(s): El Position: Proceeds Coordinator I, , the above-named affiant, under penalty of perjury, upon AFFIANTS NAME oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date El Position: Manager the above-named affiant, under penalty of perjury, upon oath, AFFIANT'S NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date ADOR 10327 (12118) Affiant's Name (as shown on page 1) P 74-e ii Bingo Affidavit • Position: Supervisor the above-named affiant, under penalty of perjury, upon oath, AFFIANTS NAME depose and say that I will be continuously present on the premises during all bingo games and until all associated activities have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date 01 Position: Assistant _ I, DONA L-' / Ke -1-1)t) ; the above-named affiant, under penalty of perjury, upon oath, AFFIANTS NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. ft/4P 4/P-, Signature of Affian Date Review Form and Sign Before Submitting Bingo Customer Service Center To avoid processing delays and errors, take a few moments to make sure you have entered all of the Locations required information and verify that it is accurate. 8:00 a.m. - 5:00 p.m. Affiant's Signature Monday through Friday Sign and date the form. (Except legal Arizona state holidays) The form can be: Phoenix Office Emailed to: 1600 West Monroe bingo@azdor.gov Phoenix, AZ 85007 Faxed to: 602-716-7973 Bingo Customer Service Telephone Mailed to: Bingo Tax Unit Number PO Box 29019 Phoenix, AZ 85038-9019 (602) 716-7801 ADOR 10327 (12/18) Page 2 Arizona Form Affidavit Bingo 830 This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404. License Number n vENUE USE ONLY. DO NOT MARK IN THIS AREA. If licensee is a qualified organization, the following section is required: lar&r? Date Joipiatf 0 nization Yes • No 10 1-5 I / Offi? Q ffi p er Tfile 4 iff Yes . Yein- 'At ' Do you have a .ffidavit on file for any other licensee? • Yes w. No If "Yes", list license number(s): ID Position: Proceeds Coordinator I, the above-named affiant, under penalty of perjury, upon AFFIANTS NAME oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date • Position: Manager the above-named affiant, under penalty of perjury, upon oath, AFFIANTS NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date ADOR 10327 (12/18) Affiant's Name (as shown on page 1) Bingo Affidavit ((A, '4/Z4, Lti 0 Position: Supervisor , the above-named affiant, under penalty of perjury, upon oath, AFFIANTS NAME depose and say that I will be continuously present on the premises during all bingo games and until all associated activities have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date LIX' Position: Assistant 11Pc 71- 1P14# puiLW , the above-named affiant, under penalty of perjury, upon oath, AFFIANTS NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Date Review Form and Sign Before Submitting Bingo Customer Service Center To avoid processing delays and errors, take a few moments to make sure you have entered all of the Locations required information and verify that it is accurate. 8:00 a.m. - 5:00 p.m. Affiant's Signature Monday through Friday Sign and date the form. (Except legal Arizona state holidays) The form can be: Phoenix Office Emailed to: 1600 West Monroe bingo@azdor.gov Phoenix, AZ 85007 Faxed to: 602-716-7973 Bingo Customer Service Telephone Mailed to: Bingo Tax Unit Number PO Box 29019 Phoenix, AZ 85038-9019 (602) 716-7801 ADOR 10327 (12/18) Page 2 Arizona Form Affidavit Bingo 830 This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404. Licensee's Name License Number 4./ LA- Xe .7,--..402 aVENUE Affiant's Name USE ONLY. DO NOT MARK IN THIS AREA. pet-e, al 0 ry-Ls _ _ S . Ad C t 1111. fiiiiiiiiiiewie) 81 PM go RCVD If licensee is a qualified organization, the following section is required: Member? Date Joined Organization GrYes UNo Q1g3 1 9-t. 1 Officers? Officer Titl rr/Yes 0 No 6/ ( /14?-S Do you have an affidavit on file for any other licensee? 0-"re-sM No If "Yes", list license number(s): /, 2_ 6 0 Position: Proceeds Coordinator the above-named affiant, under penalty of perjury, upon AFFIANT'S NAME oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date 0 Position: Manager , the above-named affiant, under penalty of perjury, upon oath, AFFIANT'S NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date ADOR 10327 (12/18) Affia ' Name (as shown on page 1) -e iZ RJA. Bingo Affidavit 0 Position: Supervisor ---1-'7-)„, I, 1 i=- / 1.-- •%-- fry/ Ot4/11 S , the above-named affiant, under penalty of perjury, upon oath, AFFIANT'S NAME depose and say that I will be continuously present on the premises during all bingo games and until all associated activities have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. z.---- gnature of Affian Date El Position: Assistant I, , the above-named affiant, under penalty of perjury, upon oath, AFFIANT'S NAME depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge. Signature of Affiant Date Review Form and Sign Before Submitting Bingo To avoid processing delays and errors, take a few Customer Service Center moments to make sure you have entered all of the Locations required information and verify that it is accurate. 8:00 a.m. - 5:00 p.m. Affiant's Signature Monday through Friday Sign and date the form. (Except legal Arizona state holidays) The form can be: Phoenix Office Emailed to: 1600 West Monroe bingo@azdor.gov Phoenix, AZ 85007 Faxed to: 602-716-7973 Bingo Customer Service Telephone Mailed to: Bingo Tax Unit Number PO Box 29019 Phoenix, AZ 85038-9019 (602) 716-7801 ADOR 10327 (12/18) Page 2