S.V.P. SUMMER BINGO_REDACTED.PDF

Application for Bingo License Packet includes:
e Arizona Form 833 — Application for Bingo License
e Arizona Form 830 — Affidavit

e Arizona Form 832 —
Endorsement by Local Governing Body

It is advisable that you obtain and review a copy of the
Arizona Revised Statutes on “Games of Bingo” and the
Administrative Rules prior to initiating an application.
These documents outline qualifications and requirements
for obtaining a bingo license and may be obtained from:

* www.azleg.gov/ and
* www.azsos.gov/public_services/table_of_contents.htm

All forms must be complete and legible. Please type or
print using black ink only. Forms are available in a fillable
pdf format at Arizona Department of Revenue (ADOR)
web site www.azdor.gov. Be sure to include on your
application a telephone number where you (or another
party responsible for the games) can be reached during
the day.

The bingo license package for new license and appropriate
fees must be sent to and approved by the local governing
body (the city council for incorporated cities or the county
board of supervisors for unincorporated areas) prior
to submission to the ADOR Bingo Section. Upon their
approval or disapproval, the local governing body will
forward the license package to the ADOR Bingo Section.

Endorsement By Local Governing Body Form

Complete lines 2, 3, and 4 of Arizona Form 832,
Endorsement by Local Governing Body and submit to
your local governing body with the bingo license package.
A bingo license cannot be issued until this form is
received by the ADOR Bingo Section.

As part of the review of your application for a bingo license,
the ADOR Bingo Section will conduct an analysis of
any purchase agreement for either equipment and/

or real property to determine that such agreement
is bona fide. This analysis is conducted pursuant to

A.R.S. 5-406.F. The Bingo Section does not “approve”
these agreements as to content or other legal ramifications.
You are strongly advised to consult with independent legal
counsel to determine your rights and obligations under
these agreements.

If you need additional forms or have any questions, please
call the ADOR Bingo Section in Phoenix at (602) 716-7801.

Clas 4

Arizona Department of Revenue Application for Bingo License Packet

CHECKLIST:

Send copies of all documents listed below unless otherwise
noted. Before mailing, check to make sure that you have
included the following:

14] Original completed Application for Bingo License
(Arizona Form 833).

-2Ef6triginal completed affidavits (Arizona Form 830).
Class B and Class C applicants must include a
completed affidavit for each person participating
in the conduct of your games. Class A applicants
must include a complete affidavit for each person
participating as a manager, proceeds coordinator
and supervisors.

~3£} Réntal agreement if more than one licensee is using
the same rented premises in which to hold bingo.

_—+Et Application for Special Bonus Game (Arizona Form
831) available at www.azdor.gov. If you do not
conduct special bonus games do not complete the

Wren
sl License fee payable to the Arizona Department of

Revenue:
License Type Fee
lass A $10.00
Class B $50.00
Class C $200.00

61 The local governing body fee will be payable to the
appropriate local governing entity:

License Type Fee
Class A__—— $5.00
Class B $25.00
Class C $50.00

7L] If applying as a qualified organization, a current
membership list must be submitted and must
indicate initial membership dates for all members
of the applicant organization. Any person from any
branch of the applicant who will be participating in the
operation of bingo games must be included on the
membership list.

aL] If applying as a qualified organization, the following
must be submitted: charter documents, articles
of incorporation, corporate bylaws, articles of
association, minutes of the establishment meeting,
and minutes of meetings for two years (two months of
each year) immediately prior to the date of application
for the applicant, parent and auxiliary.

-s—}Purchase agreement for real property (where
applicable).

104 Purchase agreement/bill of sale for bingo equipment

we. supplies.
114d Original local governing body endorsement.

ADOR 10331 (2/20)

Arizona Form 832 Endorsement by Local Governing Body Bingo

FOR OFFICIAL USE ONLY PURSUANT TO A.R.S. § 5-404.A

e License Applicants: Complete lines 2, 3, and 4. Submit with entire license package to local governing body.

e Local Governing Body: Complete and return with license package to the Department of Revenue Bingo Se’
A.R.S, §§ 5-409 and 5-410

ction.

Date License Number

(J New Application (J Change of Location

From (Name of local governing body)

Address (number and street, PO Box)

City State ZIP Code

Phone No. (with area code)

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

PM RCVD
1. This is to certify that on _ja hearing was conducted pursuant to Arizona Revised Statute, Title 5,
Chapter 4, in the matter of:
C1 Application for a bingo license by the following applicant.
Di Application for a bingo license location transfer.
.\) SS uarpormsn ENCSAN)
2 Applicant's Name NY
3 Location/Address where live ne will be conducted: | City . State |ZIP Code
Vio En Winwees A De: AMHR Toretiod | Ait} TSLgo
4 Fill in the time on the days live bingo will be played:
SUN MON TUE WED THUR FRI SAT
a.m. Oa.m. ; Cam. Olam. Oa.m. Olam. Olam.
»Op.m. |e :Op.m. |e 35 s Bap.m. |i sp... :Cp.m.}e sCp.m. sCIp.m.

5 Who is your live bingo supplier?

Cacx us BEERS

6 Recommendation for the application: [1 Approved [1 Disapproved

7 Specific reasons for disapproval are hereby listed pursuant to A.R.S. § 5-404.1:

This endorsement must be signed by a delegated authority of the local governing body.

PRINTED NAME

SIGNATURE DATE TITLE

Please mail to:
Arizona Department of Revenue
4600 W Monroe Street, Division Code 22
Phoenix, AZ 85007.

B (602) 716-7801

ADOR 10326 (2/20)

Arizona Form 833

Application for Bingo License

* Type or print in black ink and complete all information requested on this form. If you do not, your application will be returned. All
information is subject to verification. If you need more space, attach additional sheets.

« All bingo licenses expire one year from the date of issue. To continue conducting live bingo games, you must renew your license
prior to the expiration date pursuant to A.R.S. §§ 5-403(C) and 5-410.

4 Applicant's Name

SVR Summer

Falsification of information
contained in this application

Bi Pv
2a Mailing Address TS 4
Wier E. lauversiky Dr “Wa

constitutes a Class 6 felony.

2b City State
Porche Juvetion At

ZIP Code
§SI1206° 188)

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

3a Administrative Office Location
net E. Ua jversity Dr

3b Gity State
Apache Jeune tion Az2

ZIP Code
8S; Ze

4a Name of Contact Person
Dave Weaver

| PM RCVD
a0

5 Class B and Class C license applicants only: If applying as a qualified organization, check one box to indicate the type of

organization:
O1 Charitable D1 Social 0 Religious (1 Veterans
0 Fraternal 1 Volunteer Fire Department +] Homeowners Association 1 Nonprofit Ambulance Service

Class B and Class C license applicants only applying as a qualified organization, provide parent or auxiliary information:

6a Parent Name

6b Auxiliary Name

Address ~ Number and Street, Rural Rt., Apt. No.

Address — Number and Street, Rural Rt., Apt. No.

City State ZIP Code

City State ZIP Code

7 Class B and Class C license applicants only applying as a qualified organization, list the current officers or Board of

lirecto)
7a Name 7b Name
Title Title

Address — Number and Street, Rural Rt., Apt. No.

Address — Number and Street, Rural Rt., Apt. No.

City State ZIP Code City State ZIP Code
7c Name 7d Name
Title Title

Address — Number and Street, Rural Rt., Apt. No.

Address — Number and Street, Rural Rt., Apt. No.

City State ZIP Code City State ZIP Code
8 Class B and Class C license applicants only: Bingo checking account information:
Checking Account Number Bank Name Bank Branch
Continued on page 2 >

ADOR 10334 (2/20)

Applicant's Name (as shown on page 1) _.

SKF

Sun mer ka

APPLICATION FOR BINGO LICENSE

9 Class B and Class C license applicants only: Bingo interest-bearing account information:

10

11 List the name(s) of the one or two persons who will serve as managers. If applying as a qualified organization, these persons
must be members of the applicant. Each person must submit an affidavit.
41a Name 1b Name
Wi He sakten barger
Title Title
ymem ber
12 List the name of the one person designated as proceeds coordinator. !f applying as a qualified organization, this person must be
an officer or director and a member of the applicant. Each person must submit an affidavit.
Name Title
ABawekd mulse Officer + member
13 List the name(s) of the person(s) who will serve as supervisor. |f applying as a qualified organization, each person must be a

14

15

Account Number Bank Name

Bank Branch

Class B and Class C license applicants only: List all officers and/or supervisors authorized to sign checks from the accounts
listed above. If applying as a qualified organization, all supervisors must be members of the applicant:

10a Name

10b Name

Title

Title

member of the applicant. Each person must submit an affidavit.

If additional names are required, please attach affidavits.

13a Name

13b Name

Ltho fierce.
Title Title
mam ber

List the name(s) of the person(s) who will serve as assistants.
member or new member of the applicant. Except for “Class A”

If applying as a qualified organization, each person must be a
licensees, each person must submit an affidavit.

14a Name 14b Name

Jo arwA_GCreen Sue Ukhmer
14c Name 14d Name

dawkE  Wakten berger Greq iJalden

Street address of the PHYSICAL location where live bingo will be played:

lites E€ bynivetsity Dr - fpacht

Juwekron ~n2- 89120

16 Games of Bingo must not exceed 5 days a week. Indicate the time on each respective day that live bingo will be played:
SUN MON TUE WED THUR FRI SAT

Olam. Olam. ve Olam. Oa.m. Ola.m. Oa.m. Olam.

E sCIp.m.|. Dpm|_¢' 8? _fap.m.) iC] p.m. |. iC]p.m. |e sCIp.m.| sC]p.m.

Continued on page 3 >

ADOR 10334 (2/20) Arizona Form 833 Page 2 of 5

Applicant's Name (as shown on page 1)

APPLICATION FOR BINGO LICENSE

OVE Summer iDinqe

17 Indicate the type of premises where bingo will be played. Check one box:

a “a Neither rent nor mortgage will be paid from bingo funds.

b (J Rented or leased. Attach rental affidavit and copy of rental agreement.

Landlord's Name

Address — Number and Street, Rural Rt., Apt. No.

Telephone Number (with area code)

City State ZIP Code

c [J Owned solely by the organization. Attach copy of mortgage, deed of trust, purchase agreement, escrow agreement, or

other related document.

Holder of Mortgage

Address — Number and Street, Rural Rt., Apt. No.

Telephone Number (with area code)

City State ZIP Code

d (J Owned jointly with other organization. Attach copy of mortgage, deed of trust, purchase agreement, escrow agreement, or

other related document.

4) Holder of Mortgage Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code
2) Co-Owner Holder: Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code
3) Co-Owner Holder: Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code

18 List bingo licensees who are or will be conducting bingo in the same premises as you and those licensees located within 1,000

feet of your premises:

18a Name

Suv Valley fark

18b Name

Address — Number and Street, Rural Rt., Apt. No.

Address — Number and Street, Rural Rt., Apt. No.

duo, Eo leniversiléy Or
City ; “State ZIP Code City Siate ZIP Code
ApAthe. Sutakiens Az § S120
Continued on page 4 >

ADOR 10334 (2/20)

Arizona Form 833

Page 3 of 5

|
'

Applicant's Name (as shown on page 1)

S.% Pf Summer 19a APPLICATION FOR BINGO LICENSE
aI
19 Expected bingo expenses:
a Mortgage: $ per month
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
b Rent: $$ soper J month CJ hour (J occasion
Payable to (Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
c Janitorial Services: $. per {J month (hour (J occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
d_ Accounting Services: $, , per( month CJ hour (7 occasion
Payable to (Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
e Security Services: §, per [J month CJ hour [J occasion
Payable to [Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
f Bingo Supplies: g 180000 | per & mewth season
Payable to ’ Address — Number and Street, Rural Rt., Apt. No.
Cactus ia.vqo Supply Baio E Roeser - Suite (&
Telephone number (with area code) Di State ZIP Code
foo - SHU4-- 0984 hotnry AZ seve

20
your live bingo games?

o Sug phy - No

Who is your live bingo supplier? (For all bingo supplies). Do you foresee purchasing/renting machines as “technological aids for

_|

Cactus Cing

Continued on page 5 >

ADOR 10334 (2/20)

Arizona Form 833

Page 4 of 5

Applicant's Name (as shown on page 1) _
SVP Summer Brge APPLICATION FOR BINGO LICENSE
L A» HG Wa At l Wh Jt , under penalty of perjury and upon oath, declare that I am duly authorized to sign

and file this application. I hereby swear or confirm that I have read the foregoing application and know the contents thereof and that
all information provided has been fully, accurately, and truthfully completed to the best of my knowledge.

GV iprell ( LU hse = 2/ 4/3 ¢ /pveseding Od pirate’

APPLICANT'S SIGNATURE ~ DATE TITLE C7

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

B (602) 716-7801

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
{J Approved {J Disapproved (1ClassA License {[JClassB License [Class C License

Reviewer's Name (please print) Date License Number Effective Date Expiration Date

ADOR 10334 (2/20) Arizona Form 833 Page 5 of 5

.
.
.

Arizo y nee rm Affidavit Bingo

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. Ail 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 A.R.S. § 5-404.

|Licensee’s Name License Number
SivVi Ps SU mmMmER Pi N\Go
Position (check the appropriate boxes): ‘
|) Manager _EakSupervisor__[] Proceed Coordinator] Assistant [ag] NE USE oN DONT Maren TES Ane
Affiants Name
etio b. Piereee
(Social Security Number

31) PM a

if licensee is a qualified organization, complete the following section:

Daves _E1No D2 Ie. JONES
Officers? . Officer Title
\KbYes [No Sep& evi Sees

Do you have an affidavit on file for any other licensee?
DlYes {SRNo__ If “Yes”, list license number(s):

1, E Cth _4- 2, & (CC » the above-named affiant, under penalty of perjury, upon oath, 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 rales of the licensing authority. 1 am of good moral character and have never been convicted of

any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. I hereby swear or confirm that J have read
and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

Signature of Amant
ALt [POLE
Date 7

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

@ (602) 716-7801

ADOR 10327 (2/20)

Arizona Form .

Bingo

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 retumed to you. All Information is subject to verification. Disclosure of your Socal Security Number (SSN) fs voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404,

Licensee's
o.U. P. Super Tig 0

License Number

— "(check the appropriate boxes):

[gy UE USE OMLY.DO NOT MARIC EN THES AREA,

ffeqm _

if licensee is a qualified organization, complete the following section:

ves _[1 No Lb. 1", sO 2.3
Skves [1] No Navn bez

Do you have an affidavit on file for any other licensee?
0 Yes Fahno If “Yes”, list license number(s):

L ( Y \i ke AY Ie ube f Gc , the above-named affiant, under penalty of perjury, upon oath, 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. 1 am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. I hereby swear or confirm that I have read
and understand the foregoing and verify that the information and statements made

knowledge. y;

in are true and correct to the best of my

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

@ (602) 716-7801

ADOR 10327 (2/20)

Arizona Form

830

Affidavit

Bingo

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 retumed to you. Ail 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 A.R.S. § 5-404,

Licensee's Name _ License Number
SVP SUMMER Bwg9o
Position (check the appropriate boxes): a

[Cl manager [supervisor 1 Proceed Coordinator _[] Assistant

lasy "= “SE omer po Nor wacet is ance

|Affiant’s Name

AkpvolD W Mvdso

_

if licensee is a qualified organization, complete the following section:

Member? Date Joined Organization
Kd Yes CI No Yo ds. YOre
Officers? Officer Title

RI Yes CINo

Do you have an affidavit on file for any ather licensee?
Ces DX No _ If "Yes", list license number(s):

knowledge.

1 / | Yr2b ld. Mur Jew , the above-named affiant, under penalty of perjury, upon oath, 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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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

Signature of Alfiant

Date

Please mail to:
Arizona Department of Revenue

Phoenix, AZ 85007

1600 W Monroe Street, Division Code 22

@ (602) 716-7801

ADOR 10327 (2/20)

Arizona Form

830 Affidavit

Bingo

This affidavit must be compieted by each person who wishes to assist in the conduct of any game of bingo. If any information fs 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 A.R.S. § 5-404.

Licensee’s Name ? . License Number
SVP. Suro ek Din
Position (check the appropriate boxes): S
|) Manager (C1 Supervisor [1 Proceed Coordinator ‘Wlssistant fggyeine use ome DO Nor maracas ares

Work Phone No. (with area code)

F RCVD

if licensee is a qualified organization, complete the following section:

[Biives [No
Officers? . Officer Title
Yes iz ‘No

{Do you have an affidavit on file for any other licensee? +
[Ek¥es _CINo _if*Yes",listlicense number(s): © 7- 64 - A

knowledge.

the above-named affiant, under penalty of perjury, upon oath, 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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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

=
ese. O , We at LON,
t

Signature of

Date

Please mail to:
Arizona Department of Revenue
41600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

@ (602) 716-7801

ADOR 10327 (2/20)

This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information fs blank or incorrect, the
affidavit will be returned to you. Alt information is subject to verification. Disclosure of your Sodial Security Number (SSN) fs voluntary. This Information
may be used to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404.

lLicensee’s Name License Number

S.v/, P,DSLIQ\ MER BIWGO
Position (check the appropriate boxes):

[Ci Manager (CI Supervisor __[C] Proceed Coordinator [Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA,

Affiant's Name

faa] PM ee"

if licensee is a qualified organization, complete the following section:

kYes [INo 16. 23, BOW
Officers? : Officer Title
DlYes _EANo

Do you have an affidavit on file for any other licensee?
DlYes KINo__ If ‘Ves’, list license number(s):

I, lal la ) I A yet , the above-named affiant, under penalty of perjury, upon oath, 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. 1 am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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 7

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

(602) 716-7801

ADOR 10327 (2/20)

Arizona Form
830

Affidavit Bingo

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 A.R.S. § 5-404,

Licensee's N License Number
3 A, F Sum mer Biv Ge
Position (check the appropriate boxes):
M Sy Proceed Coordinator Assistant Jog] USF ONSEDO NOT MarucoY TES AREA

lia PM iat

lf licensee is a qualified organization, — the following section:

Member?

Olyes [INo

WIVATEPET

Officers?
(Yes td No

Do you have an affidavit on file for any other licensee?
O Yes TH.No If “Ves", list license number(s):

knowledge.

. a -
L / } Ak € A ) [ va) RUE , the above-named affiant, under penalty of perjury, upon oath, 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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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

Kgon) Ke — a

Signature of Affia
B39 [No
Date
Please mail to:
Arizona Department of Revenue

1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

ADOR 10327 (2/20)

@ (602) 716-7801

Arizona Form
830

Affidavit

Bingo

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. Alt Information is subject to verification. Disclosure of your Sedial Security Number (SSN) is voluntary. This information
tay be used to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404,

Ucenseq 's Name, —
Sv MU mme & Dwge

+r

License Number

Position (check the appropriate boxes):

[CU Manager [] Supervisor_[] Proceed Coordinator (AAssistant

fay eon Donor ncon Tins ane

Affiants Name

‘Social Security Number

a] PM

P RCVD

if licensee is a qualified organization, complete the following section:

Date Joy ization
Yes __[INo O/o pes

Officers? Officer Title

(1 Yes TH No

Do you have an affidavit on file for any other ficensee?
Yes No___ If “Yes”, list license number(s):

L Gren ww aldol

knowledge.

» the above-named affiant, under penalty of perjury, upon oath, 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. 1 am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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

wuld

Signatire of Affiant

2/42) ab

Please mail to:
Arizona Department of Revenue

Phoenix, AZ 85007

1600 W Monroe Street, Division Code 22

@ (602) 716-7801

ADOR 10327 (2/20)

Arizona Form

830 Affidavit

Bingo

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 retumed 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 A.R.S. § 5-404.

Licensee's .
SVP Sk MME BinCo

License Number

Position (check the appropriate boxes):

[Manager _[C] Supervisor] Proceed Coordinator {7/1 Assistant

aaa

O Tatu aren

4] PM

=

iflicensee is a qualified organization, complete the following section:

i Yes CNo / 72 Ler
rs? Officer Title 7
Yes No

Do you have an affidavit on file for any other licensee?
O yes iz No ___If*Yes", list license number(s):

knowledge.

L Ausion a y (Laver » the above-named affiant, under penalty of perjury, upon oath, 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. 1 am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. I hereby swear or confirm that J have read
and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

Aupen C Ube

Signature of Affiant

mall 1/2629

Please mail to:
Arizona Department of Revenue

Phoenix, AZ 85007

1600 W Monroe Street, Division Code 22

@ (602) 716-7801

ADOR 10327 (2/20)

Arizo a a youn Affidavit Bingo

This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. Tf any information is blank or incorrect, the
affidavit will be returned to you. Alt information Is subject to verification. Disdosure of your Sodal Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404.

lLicensee’s Name - . License Number

SVP Sommer Bing

Position (check the appropriate boxes): a)

|] Manager [1] Supervisor [1] Proceed Coordinator [assistant fee UE OND DO NOT maracas AREA
E Coevtin_ _

p= =

if licensee is a qualified organization, complete the following section:

‘Member? Date Joined Organization
fyes__[INo YW OF, 9025
Officers? . Officer Title

Yes [No

Do you have an affidavit on file for any other licensee?
O Yes ExNo If “Yes”, list license number(s):

, CMARLorr Ee

| ams DO We the above-named affiant, under penalty of perjury, upon oath, 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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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.

amaue es ZF
yb | Yor
Date

7

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

TB (602) 716-7801

ADOR 10327 (2/20)

Affidavit

Arizona Form
830

Bingo

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) fs voluntary. This Information

may be used to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404.

Licensee's Name

SV. PP. Summer Pinga

License Number

Position (check the appropriate boxes):
[CI manager _[] Supervisor [C1] Proceed Coordinator Palassistant

feet Fm oo nor marc san

Be

i RCVD

WKYes [INo
Officers? Officer Titie
[ J Yes Ko

Do you have an affidavit on file for any other licensee?
Llyes EANo __if“Yes", list license number(s):

knowledge.

the above-named affiant, under penalty of perjury, upon oath, depose
and sly at 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. | am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. 1 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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

Signature fhment
{
\

‘ Lane eo Yen gus

Date

Please mail to:

Phoenix, AZ 85007

Arizona Department of Revenue
1600 W Monroe Street, Division Code 22

@ (602) 716-7801

ADOR 10327 (2/20)

Arizo a a rm Affidavit Bingo

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. Ail information Is subject to verification. Disclosune 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 A.R.S. § 5-404,

Licensee's Name_ License Number

SVP Summek. Bingo

Position (check the appropriate boxes):

|] Manager 7] Supervisor__[] Proceed Coordinator Passistant egy env no Mor waren nes ae

if licensee is a qualified organization, complete the following section:

Date Joined Organization
[CiNo
Officers? . Officer Title
Elves [No
Do you have an affidavit on file for any other licensee?
OlyYes No _If*Yes”, list license number(s):

VA tC Q ( \ealso , the above-named affiant, under penalty of perjury, upon oath, 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. 1 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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

ams S Affiant

Lis

Please mail to:
Arizona Department of Revenue
41600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

@ (602) 716-7801

ADOR 10327 (2/20)

Cactus Bingo Supply, LLC.
3210 E Roeser Rd Suite 15
Phoenix, AZ 85040
800-544-0984

www.cactusbingosupply.com
SUN VALLEY PARK

Sold To: 41101 E UNIVERSITY #145
APACHE JUNCTION, AZ 85220

Ship To: 11101 E UNIVERSITY #145

SUN VALLEY PARK

Invoice # 5B05104

Date: 03/10/2026
Terms: Net 30

Customer #: 00-SVP
Whse/SP: 000/Lloyd Ea

APACHE JUNCTION, AZ 85220

ltem # Description Unit = Shpd BO Price Amount
ICV3STP 30Z DAB-O ST. PATRICKS, PER DZ DOZ 7.00 - 13.68 $95.76
94020001003 110ML DABBIN FEVER ORANGE DOZ 1.00 - 14.08 $14.08
94020001011 110ML DABBIN FEVER YELLOW Doz 1.00 - 14.08 $14.08
94020001019 110ML DABBIN FEVER PURPLE DOZ 1.00 - 14.08 $14.08
94020001021 110ML DABBIN FEVER FUCHSIA DOZ 1.00 - 14.08 $14.08
94020001005 110ML DABBIN FEVER PINK DOZ 1.00 - 14.08 $14.08
2222 FREIGHT/DELIVERY - SCANNER EACH 1.00 - 15.00 $15.00
ps. apa)
V Ae joe $
Az $160.16 500% $031 Net: $181.16
PHX $166.16 2.80% $4.65 Discount 0.00% $0.00
MARI $166.16 1.30% $2.16 Freight: $0.00
Tax:
Total: 106 28>

Cust Sig.: Date:

Page 1 of 1

Outrajus Technologies, LLC
9500 Osuna Rd NE #424
Albuquerque, NM 87111
502-649-4215

Invoice # 01/06/2024

Customer: Sun Valley Park
11101 E. University St.
Apache Junction, AZ 85120
Attn: Jan & Diane

Windows 19” All-in-One Touchscreen CPU - Refurbished with 1 year warranty. Includes
HD camera, accessories, and Lifetime Software license for Virtual Bingo System.

$4,049.00
Shipping $50.00
Total this invoice: $4,099.00

We appreciate your business!

Please remit payment to:
Joe Kepler