LOST DUTCHMAN SOCIAL CLUB_REDACTED.PDF
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Application for Bingo License Arizona Form 833 • 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 bingo games, you must renew your license prior to the expiration date. 1 Applicant's Name Lost Dutchman Social Club 2a Mailing Address 10936 E. Apache Trail #1007 2b City Apache Junction State ZIP Code AZ 85120 3a Administrative Office Location 10936 E. Apache Trail #1007 3b City Apache Junction State ZIP Code AZ 85120 4a Name of Contact Person Linda Potter 4b Tele • hone No. 4c E-mail Address 4c Fax No. Falsification of information contained in this application constitutes a Class 6 felony. REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 88 PM 80 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: El Charitable El Social El Religious El Veterans El Fraternal El Volunteer Fire Department El Homeowners Association El 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. 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, provide the date the organization was established in Arizona: i , I 8 Class B and Class C license applicants only applying as a qualified organization, list the current officers of the organization: 8a Name 8b 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 8c Name 8d 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 Continued on page 2 4 REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 0 Approved 0 Disapproved C3 Class A License CI Class B License 0 Class C License Reviewer's Name (please print) Date License Number Effective Date Expiration Date ADOR 10334 (1/14) Previous 71-1010 (4/06) Applicant's Name (as shown on page 1) Lost Dutchman Social Club APPLICATION FOR BINGO LICENSE . . Checking Account Number .. Bank Name Bank Branch . . Account Number .. - Bank Name Bank Branch 11 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: 11a Name 11b 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 12 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. 12a Name Linda Potter 12b Name Title Manager 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 13 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 - Numhar and Strpet Rural Rt., Apt. No. Linda Potter Title City State ZIP Code Proceeds CoOrdinator 14 List the name(s) of the person(s) who will serve as supervisor. If applying as a qualified organization, each person must be a member of the applicant. Each person must submit an affidavit. 14a Name Mike Potter 14b Name Paul Kaminski Title Supervisor Title Supervisor Address - Number and Street, Rural Rt., Apt. No. Address - Number and Street, Rural Rt., Apt. No. Cit State ZIP Code Cit State ZIP Code 14c Name • • lame 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 9 10 ADOR 10334 (1/14) Arizona Form 833 Page 2 of 5 Previous 71 -1010 (4/06) Applicant's Name (as shown on page 1) Lost Dutchman Social Club APPLICATION FOR BINGO LICENSE 15 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. 15a Name 15b Name 15c Name 15d Name 15e Name 15f Name 15g Name 15h Name 16 Street address of the physical location where bingo will be played: 10936 E. Apache Trial. Apache Junction. AZ 85120 17 Indicate the time on each respective day that bingo will be played: SUN MON TUE WED THUR FRI SAT , 7:00 ['a.m. Dam. • a.m. • a.m. MI a.m. lam. lam. p m pm , , p m Up m , , Elp m , , • p m . • p.m. 18 List dates of proposed game cancellation if any: End of March to the beginning of Novemeber each year 19 Indicate the type of premises where bingo will be played. Check one box: a gi Neither rent nor mortgage will be paid from bingo funds. b CI 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 ri 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 173 Owned jointly with other 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 Continued on page 4 4 ADOR 10334 (1/14) Arizona Form 833 Page 3 of 5 Previous 71 -1010 (4/06) Applicant's Name (as shown on page 1) Lost Dutchman Social Club APPLICATION FOR BINGO LICENSE 20 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: 20a Name Lost Dutchman Park 20b 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 21 Expected bingo expenses: a Mortaaoe: $, , per month Payable to Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code b Rent: Si per CI month 0 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 0 month hour 0 occasion Payable to Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code d Accounting Services: $, , per 0 month 0 hour 0 occasion Payable to Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code e Security Services: $, per 0 month 0 hour 0 occasion Payable to Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code f Bingo Supplies: $,500.00 , per Season Payable to Cactus Bingo Address — Number and Street, Rural Rt., Apt. No. 3210 E. Roeser Rd.. Suite 15 Telephone number (with area code) (602) 268-2848 City Phoenix State AZ ZIP Code 85040 Line 21 continues on page 5 4 ADOR 10334 (1/14) Previous 71 -1010 (4/06) Arizona Form 833 Page 4 of 5 Applicant's Name (as shown on page 1) Lost Dutchman Social Club APPLICATION FOR BINGO LICENSE 21 Expected Bingo Expenses, continued... g Maximum prize payout per occasion: $300.00 ,. Attach game schedule that lists individual prize amounts. Paid to Individual Winners Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code h Utility Expenses: Electric (payable to) Address — Number and Street, Rural Rt., Apt. No. Account Number Monthly Amount $ City State ZIP Code Gas (payable to) Address — Number and Street, Rural Rt., Apt. No. Account Number Monthly Amount $ City State ZIP Code Water (payable to) Address — Number and Street, Rural Rt., Apt. No. Account Number Monthly Amount $ City State ZIP Code Trash Removal (payable to) Address — Number and Street, Rural Rt., Apt. No. Account Number Monthly Amount $ City State ZIP Code 22 Briefly state the specific projected use of net proceeds from games of bingo: Most proceeds will be paid out in prize money. I, Linda Potter , 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. Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 n (602) 716-7801 ADOR 10334(1/14) Arizona Form 833 Page 5 of 5 Previous 71-1010 (4/06) Lost Dutchman Social Club Bingo Color Game 1 Blue Regular Bingo ** 2 Orange Small Diamond plus 4 corners 3 Green Any 3 Corner Brackets 4 Yellow 8 Pack anywhere (wild #) 5 Gray Odd/Even Cover-All Intermission 6 Lime 7 Brown 8 Red 9 Purple 10 Aqua Floating 6 pack (wild #) Crazy Small Kite Letter' X' "Check" mark Cover-All **Regular bingo's are Verticle, Horizontal or Diagonal line, or 4 Corners or a Postage Stamp Each game will pay $30.00 Address (number and street, PO Box) City Phone No, (with area code) 88 State ZIP Code Arizona Form 832 Endorsement by Local Governing Body Bingo FOR OFFICIAL USE ONLY PURSUANT TO A.R.S. § 5-404.A O License Applicants: Complete lines 2, 3, and 4. Submit with entire license package to local governing body. • Local Governing Body: Complete and return with license package to the Department of Revenue Bingo Section. New Application J Change of Location Date License Number From (Name of local governing body) REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 1 This is to certify that on i i i i a hearing was conducted pursuant to Arizona Revised Statute, Title 5, Chapter 4, in the matter of: O Application for a bingo license by the following applicant. O Application for a bingo license location transfer. 2 Applicant's Name Lost Dutchman Social Club 3 Location/Address where games will be conducted: City 10936 E. Apache Trail Apache Junction 4 Fill in the time on the days games will be played: State ZIP Code AZ 85120 SUN MON TUE WED THUR FRI SAT a.m. p m ,7:00 a.m. i I I I a.m. P M I II II • a.m. • a.m. • a.m. • • a.m. , , • , F2 pm El p m illpm i Op m . I 0 p.m. 5 Background investigations: 0 have 0 have not been conducted on all individuals listed in the Bingo License Application. 6 Recommendation for the application: 0 Approved 0 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, PO Box 29019, Phoenix, AZ 85038-9019 ADOR 10326 (1/14) n (602) 716-7801 Previous 71-1002 (4/06) If licensee is a qualified organization, complete the following section: 88 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 Arizona Revised Statutes § 5-404. Licensee's Name License Number Lost Dutchman Social Club Position (check the appropriate boxes): El Manager 0 Supervisor El Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. Member? Date Joined Organization I I D Yes KI No Officers? Officer Title • Yes El No Do you have an affidavit on file for any other licensee? 07-404-A g Yes • No If "Yes", list license number(s): I, Linda Potter 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. ///6100J0 Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 Tr (602) 716-7801 RECEIVE ADOR 10327 (1/14) Previous 71 -1 003 (4/06) JAN 21 2020 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS , the above-named affiant, under penalty of perjury, upon oath, depose 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 Arizona Revised Statutes § 5-404. Licensee's Name License Number Lost Dutchman Social Club Position (check the appropriate boxes): 0 Manager Supervisor 0 Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 88 Affiant's Name Paul Kaminski Social Security Number .._ iP1t Eir1Il - • Address City Home Phone No. with area code) State ZIP Code Work Phone No. (with area code) If licensee is a qualified organization, complete the following section: Member? Date Joined Organization I I • Yes 0 No Officers? Officer Title MI Yes I14 No Do you have an affidavit on file for any other licensee? 0 Yes IEI No If "Yes", list license number(s): I, Paul Kaminski , the above-named affiant, under penalty of perjury, upon oath, depose AFF1ANT'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. iozo Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 la (602) 716-7801 RECEVED JAN 21 2020 ADOR 10327(1/14) Previous 71-1003 (4/06) MARICOPA COUNTY CLERK BOARD OF SUPERVISORS 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 Arizona Revised Statutes § 5-404. Licensee's Name Lost Dutchman Social Club License Number Position (check the appropriate boxes): 0 Manager Supervisor 0 Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 88 Affiant's Name Michael R. Potter Social Securit Number Date of Birth Address City Home Phone No. with area code) State ZIP Code Work Phone No. (with area code) If licensee is a qualified organization, complete the following section: Member? El Yes [8:1 No Date Joined Organization I I Officers? Officer Title • Yes 0 No Do you have an affidavit on file for any other licensee? 07 -404 -A e Yes El No If "Yes", list license number(s): I, Michael R. Potter , 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 Wilds 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. Signature of Affiant '1"-‘92—° Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 tt (602) 716-7801 ADOR 10327(1/14) Previous 71-1003 (4/06)