SCW BOOMERS CLUB_REDACTED.PDF

Maricopa County — Formal (2024-08-07)

Extracted text (via ocr_local) 24270 characters

Class A

Arizona Department of Revenue Application for Bingo License Packet

This 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.azileg.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
a re ‘eement for ei i

or ‘ope! o_de ine that such agreement
i a_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.

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

RECEIVED
JUL 11 2024

CHECKLIST:

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

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

2IX] Original 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] Rental agreement if more than one licensee is using
the same rented premises in which to hold bingo.

4 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

application.
54 License fee payable to the Arizona Department of
Revenue:
License Type Fee
4 Class A $10.00
$50.00
Class C $200.00

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

License Type Fee
ctClass 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.

sL] 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.

9] Purchase agreement for real property (where
applicable).

10L] Purchase agreementbill of sale for bingo equipment
and supplies.

11{¥1 Original local governing body endorsement.

anon \ATIOEE RT SORA. COU
ADoR 10331 (@ERK BOARD OF SUP

INFY
ERVISORS

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.

1 Applicant's Name
SCW Boomers Club

Falsification of

2a Mailing Address

contained in this application
constitutes a Class 6 felony.

information

2bCi

State ZIP Code

3a Administrative Office Location
14401 West R.H. Johnson Blvd

3b City State ZIP Code
Sun City West AZ 85375

4a Name of Contact Person 4b Telephone No.
Pam Kiest

4c E-mail Address

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

4c Fax No.

feqP™

RCVD

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

organization:
1 Charitable
(1 Fraternal

(I Social

(1 Volunteer Fire Department

(1 Religious
(1 Homeowners Association

(1 Veterans

(1 Nonprofit Ambulance Service

6 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.

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

Directors of the organization:

Ta Name

7bName

Title

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)

SCW Boomers Club APPLICATION FOR BINGO LICENSE

413

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

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.

11a Name 11b Name
Richard J. DeSio Susan Crabtree
Title Title

member Boomer VP-1

List the name of the one person designated as proceeds coordinator. If 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

Deborah Schmitt Boomer Treasurer

List the name(s) of the person(s) who will serve as supervisor. |f applying as a qualified organization, each person must be a
member of the applicant. Each person must submit an affidavit. If additional names are required, please attach affidavits.

13a Name 13b Name

Pam Kiest Sheldon Miller
Title Title

Boomer President Boomer VP-2

List the name(s) of the person(s) who will serve as assistants. If applying as a qualified organization, each person must be a
member or new member of the applicant. Except for “Class A” licensees, each person must submit an affidavit.

14a Name 14b Name
Phyllis DeSio Phil McWilliams
14c Name 14d Name
Janet Rosauer Susan Peterson

Street address of the PHYSICAL location where live bingo will be played:
14401 West R H Johnson Blvd, Sun City West, AZ 85375 (Bingo no more than 2x per month, one Sun + one Wed) |

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. Olam. Olam. Olam. Olam. Olam.
2-4:30_fifp.m. iEJp.m. fe Cp.m. |. 6-8:30 p.m. _CIp.m. E]p.m. 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)

SCW Boomers Club

APPLICATION FOR BINGO LICENSE

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

a {& Neither rent nor mortgage will be paid from bingo funds. Recidéent owed tar (Mg

b [J Rented orleased. 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:

1) 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:

48a Name
none

18b Name

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

City State ZIP Code

Continued on page 4 >

ADOR 10334 (2/20)

Arizona Form 833

Page 30f5

Applicant's Name (as shown on page 1)

SCW Boomers Club

19 Expected bingo expenses:

APPLICATION FOR BINGO LICENSE

a Mortgage: $C spermonth
Payable to Address ~ Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
b Rent: $ per 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 (J 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 [J month (J hour (J 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 (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: $1,000.00 , per_year

Payable to Address — Number and Street, Rural Rt., Apt. No.
Cactus Bingo Supply LLC 3210 E Roeser Rd., Suite 15
Telephone number (with area code) City State ZIP Code
(602) 268-2848 Phoenix AZ 85040

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

Cactus Bingo Supply LLC - No technological aids will be used.

ADOR 10334 (2/20)

Continued on page 5->

Arizona Form 833

Page 4 of 5

Applicant's Name (as shown on page 1)
SCW Boomers Club APPLICATION FOR BINGO LICENSE

I, Pam Kiest , under penalty of perjury and upon oath, declare that | 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.

A loot OT- 4 _2Y SCW Boomer Club President
DATE THLE

APPLICANT'S SIGNATURE
Please mail to:
Arizona Department of Revenue
41600 W Monroe Street, Division Code 22
Phoenix, AZ 85007
@ (602) 716-7801
REVENUE USE ONLY, DO NOT MARK IN THIS AREA.
{J Approved (J Disapproved (IClassALicense {JClass B License {Class C License
Reviewer's Name (please print) Date License Number Effective Date Expiration Date

ADOR 10334 (2/20) Arizona Form 833 Page 50f5

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 Section.

A.R.S. §§ 5-409 and 5-410

oo | Date License Number
{J New Application [I Change of Location [59 7) 497 24
From (Name of local governing body)
Maricopa County Clerk of the Board of Su pec uiser> REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
‘Address (number and street, PO Box) r
301 W Jefferson St., 10th floor
City State ZIP Code
Phoenix AZ. 85003
Phone No. (with area code)
(602) 506-3766

PM RCVD

1 This is to certify that on a hearing was conducted pursuant to Arizona Revised Statute, Title 5,

Chapter 4, in the matter of:

{I Application for a bingo license by the following applicant.
C1 Application for a bingo license location transfer.

2 Applicant's Name
SCW Boomers Club

3 Location/Address where live bingo will be conducted:

14401 West RH Johnson Blvd

City
Sun City West

State
AZ

ZIP Code
85375

4 Fill in the time on the days live bingo will be played: (NO more Han <P er MEnTh One SUV tone wed )

SUN MON TUE WED THUR FRI SAT
Olam. Olam. Olam. Olam. Olam. Olam. Olam
2-4:30_, Rp.m. _3C]p.m Cp.m.|§-8:30__, S2p.m. Op.m. Cip.m. (p.m

5 Whois your live bingo supplier?

Cactus Bingo Supply LLC, 3210 E Roeser Rd., Suite 15, Phoenix, AZ - No technological aids

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

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

PRINTED NAME

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

SIGNATURE

DATE

TITLE

Please mail to:

Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

@ (602) 716-7801

ADOR 10326 (2/20)

Arizona Form
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 A.R.S, § 5-404.

Licensee’s Name

Affidavit Bingo

License Number
SCW Boomers Club
Position (check the appropriate boxes):

1 Manager DA supervisor [1 Proceed Coordinator oO Assistant
7

Affiant’s N:
EO} mela.

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

RCVD
Work Phone No. (with area code)
None
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
ClyYes [No
Officers? Officer Title
Dyes [No

Do you have an affidavit on file for any other licensee?
Dyes [No _ If"Yes”, list license number(s):

I, _ Wy Me CH Ki <€ at _, the above-named affiant, under penalty of perjury, upon oath, depose

TANTSNAME =—————~—~C—

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. Ly

Signature of Affiant

07-10 - AY

Arizona Form
830

Licensee's Name License Number

SCW Boomers Club
Position (check the appropriate boxes):

1 Manager _[7] Supervisor ww Proceed Coordinator _[[] Assistant ed USE ONLY. DO NOT MARK IN THIS AREA,
88}

Affidavit Bingo

Affiant’s Name

: i a i of ™
‘ Stat

Work Phone No. (with area code)

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

Member? Date Joined Organization
[ClYes_EINo

Officers? Officer Title

Clyes [No

Do you have an affidavit on file for any other licensee?
ClYes [No _If"Yes’, list license number(s):

I, Deborak Sthrnitt” , the above-named affiant, under penalty of perjury, upon oath, depose

AFFIANT S NAME
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.

Aberad ipomtt

Signature of Affiant

Pho [2 Zy

Date

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

Licensee's Name . License Number

SCW Boomers Club

Position (check the appropriate boxes):

(Cl Manager PX} Supervisor__[[] Proceed Coordinator__ [7] Assistant ah USE ONLY. DO NOT MARK IN THIS AREA.
88

Affiant's Name

SHELDON) WW. 111 Va

3 |

PM RCVD

Home Phone No. (with area code) Work Phone No. (with area code) "
If licensee is a qualified organization, complete the following section: /A_-
Member? Date Joined Organization

Yes__E1No
Officers? Officer Titl
Byes [INo Vick. UrestDesT 2.
Do you have an affidavit on file for any other licensee?
[Yes A No __ If “Yes”, list license number(s):

’
1, ey A ezDow Lo. 1) ( / / Ce , the above-named affiant, under penalty of perjury, upon oath, depose

AFFIANT'S NAME
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. Iam 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.

*“SighAture of Affiant Ge

F-(0- ROOT

Date

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

@ (602) 716-7801

ADOR 10327 (2/20)

Arizona Form
830

Affidavit

Bingo

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

Licensee's Name

SCW Boomers Club

License Number

Position (check the appropriate boxes):

Manager _[C] Supervisor__ [7] Proceed Coordinator [7] Assistant

Affiant's Name
‘Behaer Jd. DeSio

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

Work Phone No. (with area code)

fea] PM

RCvD

If licensee is a qualified organization, complete the following section: (/-

Member? Date Joined Organization
IKKi ves [INo

Officers? Officer Title

Clyes _XLNo

Do you have an affidavit on file for any other licensee?

Yes No _ [f"Yes”, list license number(s):

AFFIANT'S NAME

knowledge.

I, “ichae T ‘DeS ie) , 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. | 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

July fa) f 2024.

Date g

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

€ (602) 716-7801

ADOR 10327 (2/20)

Affidavit Bingo

- Arizona Form:
830

SCW Boomers Club
Position (check the appropriate boxes):

[Kl Manager _[] Supervisor__[C] Proceed Coordinator__ [7] Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
's Name

Affiant':
Susan Cralor ree

year lL

PM RCVD
Work Phone No. (with area code)
If licensee is a qualified organization, complete the following section: vA
Member? Date Joined Organization
Dives [INo
Officers? Officer Title,
Byes _CINo Vice Vresident
Do you have an affidavit on file for any other licensee?
[1 Yes rs No __If"Yes”, list license number(s):
I, Qusam Crabtree , the above-named affiant, under penalty of perjury, upon oath, depose

AFFIANT'S NAME
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. | 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 Affiant

1 -\0- 2024

Date

knowledge.

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

8 (602) 716-7801

ADOR 10327 (2/20)