SOUL SMILING OUT LOUD _ REDACTED.PDF

Maricopa County — Formal (2022-01-21)

Extracted text (via ocr_local) 30151 characters

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.

ARS. §§ 5-409 and 5-410

New Application (J Change of Location

Date

License Number

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, a hearing was conducted pursuant to Arizona Revised Statute, Title 5,

Chapter 4, in the matter of:

& Application for a bingo license by the following applicant.
Application for a bingo license location-transfer.

2 Applicant's Name
Smiling Out Loud (SOuL)

3 Location/Address where live bingo will be conducted: | City State |ZIP Code
22155 N. Mission Drive Sun City West AZ 85375
4 Fill in the time on the days live bingo will be played:
SUN MON TUE WED THUR FRI SAT
Oa.m. Olam. Ola.m. Olam. Olam. Ola.m. Olam.
:Cp.m.|h sOp.m.).4t06 Rp.m.| sOp.m.}. sOp.m.}. sOp.m.h sO)p.m.

5 Who is your live bingo supplier?
n/a

6 Recommendation for the application: [J Approved [1] 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.

@B (602) 716-7801

1 hy
SIGNATURE DATE TITLE mail Wik
Please mail to:
Arizona Department of Revenue RECEIVED
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007 NOV 01 2023

BAAD ICDA Copa
RA AH

ADOR 10326 (2/20)

CLERK BOARD OF SUPERVISORS

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.
i Seine outte 4 (SOuL Falsification of information
miling Out Loud (SOut) contained in this application

2a Mailing Address
i ti‘sd constitutes a Class 6 felony.

State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Oe Se
3b City State ZIP Code
4a Name of Contact Person 4b Telephone No.

Bonnie Gentry
4c E-mail Address 4c Fax No. PM 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:

J Charitable 1 Social 1 Religious (1 Veterans
1 Fraternal 0 Volunteer Fire Department [1] Homeowners Association (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
WA
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, fist the current officers or Board of.
Directors of the organization:
7a Name 7b Name
Bonnie Gentry Kathy Carmickle
Title Title
President ‘Treasurer
Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.
State ZIP Code State ZIP Code
ic Name 7aName
Linda Wright Judith Phillips
Title Title
Vice President Secretary
Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.

State ZIP Code

Bank Branch

Continued on page 2 >

ADOR 10334 (2/20)

Applicant's Name (as shown on page 1)

Smiling Out Loud (SOuL)

APPLICATION FOR BINGO LICENSE

9 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

Bonnie Gentry Kathy Carmickle
Title Title

President Treasurer

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.

Member at Large (elected)

11a Name 41b Name
ICherly Kennedy Carla Smith
Title Title

Memeber at Large (elected)

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
Kathy Carmickle

Title
Treasurer

List the name(s) of the person(s) who will serve as supervisor.
member of the applicant. Each person must submit an affidavit.

If applying as a qualified organization, each person must be a
If additional names are required, please attach affidavits.

13a Name 13b Name
Bonnie Gentry Linda Wright
Title Title

President Vice President

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

Judith Bourd Barbara Wilson
14c Name 14d Name

Debra Humpal Po Plantz

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

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
Oa.m. Olam. Dam. Olam. Ola.m. Dam. Olam.
Cip.m. (Op.m.|_4 to 6 _Balp.m. p.m. Cp.m. Cp.m.|. —[Ip.m.

Continued on page 3

ADOR 10334 (2/20)

Arizona Form 833

Page 2 of 5

Applicant's Name (as shown on page 1)

Smiling Out Loud (SOuL)

APPLICATION FOR BINGO LICENSE

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

a_ 6 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:

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:

18a Name

18b Name

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

City State

ZIP Code

City State ZIP Code

Continued on page 4 >

ADOR 10334 (2/20)

Arizona Form 833

Page 3 of 5

Applicant's Name (as shown on page 1)
Smiling Out Loud (SOuL) APPLICATION FOR BINGO LIGENSE

19 Expected bingo expenses:

a Morlgage: s_N] A, per month

Payable to [Address — Number and Street, Rural Rt., Apt. No.

Telephone number (with area code) City State ZIP Code
b Rent: s_N A per month (hour (4 occasion

Payable to Address — Number and Street, Rural RL, Apt. No.

Telephone number (with area code) City State ZIP Code
c Janitorial Services: §, wl A , perf} month (hour (7 occasion

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

Telephone number (with area code) City Slate ZIP Code

d= Accounting Services: fA, per {J month (Jhour (J occasion

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

Telephone number (with area code) City State ZIP Code
e Security Services: Aol it , per() month OC 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: $100.00 per _quarter

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

vendors (various

Telephone number (with area code) City State ZIP Code

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

your live bingo games?
NIA |

We Sureen+ ly OWn

We SAywe ‘ p Men + Continued on page 5 >

ADOR 10334 (2/20) Arizona Form 833 Page 4 of S

Applicant's Name (as shown on page 1)

[Smiling Out Loud (SOuL)

APPLICATION FOR BINGO LICENSE

1, Bonnie Gentry

‘e re
ee, ee re | itn Alin fl -\4 .) > President

, 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.

APPLICANT'S SIGNATURE \ DATE TITLE
Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007
@ (602) 716-7801
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
(Approved (1 Disapproved (IClassALicense (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

Smiling Out Loud (SOuL) application for Bingo license

Addendum to #14 - List names of persons who will serve
as assistants:

Gail Garey

Tracy Lewchuk
Judith Phillips
Carolyn Pakan
Carol Courter
Suzanne Brungardt

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.

‘eenseegme Ss O U L.

License Number

Position (check the appropriate boxes):

[2] Manager [1] Supervisor _[7] Proceed Coordinator

PAyassistant
?

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

feo] RVD

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

Member? Date Joined Organizati
es [No 1d) | 2)
cers? Officer Title
Yes [No Mentor ak hang

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

S
DlYes_. Extlo __ if “Yes”, list license number(s):

1,
TRANS

for ny participation in the conduct of bingo games except as provided for by law.

knowledge.

Signature of Affiant

\ 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. 1am 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

and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

. G-7-2DeS

I hereby swear or confirm that I have read

Date

Please mail to:
Arizona Department of Revenue

Phoenix, AZ 85007

4600 W Monroe Street, Division Code 22

® (602) 716-7801

ADOR 10327 (2/20)

Arizona Form
830

Affidavit Bingo

Licensee's Name License Number

S yu Le [ siti ACY Out Loud ) |
Position (cl

heck the appropriate boxes):

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

O Manager Ww Supervisor 1 Proceed Coordinator 1 Assistant

Affiant's Name ~
Bonnie L. Gankre

Social Security Number

RCVD

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

Member? Date Joined Organization
yA] Yes [1 No U~\-\G

| Officers? Offcer Title

Nl Yes [EINo ¥ resident

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

wr he

AFFIANT'S NAME

and say that I will conduct or assist in conductikg all bingo games in compliance with the terms of the license, Arizona Revised

A , the above-named affiant, under penalty of perjury, upon oath, depose

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

knowledge.

Signature of Affiant

“\-% 2D

Date

Please mail to:
Arizona Department of Revenue
14600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

® (602) 716-7801

ADOR 10327 (2/20)

Affidavit Bingo

Arizona Form
830

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

Licensee's Name

Soul

License Number

Position (check the appropriate boxes):

[1 Manager [CJ Supervisor [2] Proceed Coordinator {id Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

Affiant’s Name »)
AROLY AL | AKL

Social Security Number

PM RCVD

iT oo

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

Member? Date Joined Organization
GiYes [INo 8-20] 9
Officers? Officer Title

[DlYes__ No

Do you have an affidavit on file for any other licensee?
Yes ivi] No __ if “Yes”, list license number(s):

1, y /, wt ei , 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

knowledge.

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)

| C

If licensee is a qualified organization, complete

arol Fairchild

Bingo

Affidavit

nation is blank or inc
N) is voluntary. This inf

hes to assist in the conduct o
to verification. Disclosure ¢
of criminal background ch

ny game
your ‘

ach person who ¥
nation is sub
ion for purpos

t be complet

returned to

Ny (check thy pr boxe
IS AREA

REVENUE USE ONLY, 00 NOT MARK

the following section

Dat ned Organization
|

ee9g -
Ollie e
MemMseR KT LARGE |

n file for any other license

> number(s)

st in conducting all bingo games in compliance with the terms of the license, Arizona Revised

vill cc

n hapter 4, and the rules of the licensing authority. | am of good moral character and have convicted of

11 isdemeanor invol noral turpitude or felony, 1 haye 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. | hereby swear or confirm that I have read

nd understand the foregoing and verity that the information and statements made

herein are true and correct to the

nowleda

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

Phoenix, Az 85007 __ — =

@ (602) 716-7801

Arizona Form
: 830

This affldavit 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 fo: urposes of criminal background checks pursuant to A.R.S, § 5-404,

Affidavit Bingo

License Number

at Security Number

PM faa] RCvO
Work Phone No. (with area code) an] |
if licensee is a qualified organization, complete the following section:
' ? tg_ Joined Organization
ives CNo i)
lottegrs > | Officer Tite
Eves C1No Member at lapas
Do you have an affidavit ‘on file for any other licensee? |
Clyes No _ If “Yes", list license number(s): oe
kW ij i —— the above-named affiant, under penalty of perjury, upon oath, depose

Li
—TAEFTAN T'S RARE

and say that 1 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. Lam of good moral character and have never been convicted of
iny misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense

tor 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 (o the best of my

knowlec

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

ADOR 10327 (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
be returned to you. All information is subject to verification. Oisclosure of your Social Security Number (SSN) is voluntary. This information
to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404.

Affidavit Bingo

affidavit
may be us

icansee

D2 ER WEE Bowrider aos oen railing | |
“a

ilion (check the appropriate boxes)

0 Manager Ct Supervisor 0 Pre

ged Coordinator tH Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA

Alffiant's Nar

su Pnwe Pave oT

Security Number

een

Vork Phone No, (with area code}

is a que alifie d organization, comple: te fhe following s section:

]Date Joined Organization
C1 No - _|ROL90

|Otficer Title

ae?

do you have an affidavit on file for any other lic

Ores (1 flo lt "Yes", list

ense number(s):

i Lage 2iUMeE Brav We ADT _ _.. the above-named affiant, under penalty of perjury, upon oath, depose

} AFFIARTS NAME
and say that I will conduct or assist in conducting all Binge games in compliance with the terms of the license, Arizona Revised

Statutes, Tide 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. [ 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. 1 hereby swear or confirm that | have read

and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

. eee Murrgndt _

Signature oftfiant

knowledge

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

3 (602) 716-7801

Affidavit Bingo

by 1 bA

ty Nur 1

t licensee is a qualified organization, complete the following section
ber? Yate Joined Organization

One ao Mf)

J Vic.
O No | View Presi dent

an pitidavet ¢

No if Yes’, list license nur

L -{N DAF Mv y/ Rie HT the above-named affiant, under penalty of perjury, upon oath

vill conduct or 4 in conducting all bing 5 in compliance with the terms of the license, Arizona Revised
Starlite 5. Chapter 4, and the rules of the licensing authority. Lam of ood moral character and have never been convicted ol
wy misdemeanor involving moral turpitude oF felony, [have not < all net rec any reward, compensation or recompelise

tion in the conduet of bingo games except gs provided for by law. I hereby swear or confirm that | have rei

ivi

snd understand the foregoing and verify that the mformation and statements made herein are tue and correct to the best of my

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

aol a 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. Discosure of your Social Security Number (SSN) is voluntary. This information

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

License Number

i (Srubing owkLoud )

Ty appropriate boxes

Position

(] Manager _[(C) Supervisor [1] Proceed Coordinator assistant

[Affiant’s Name

eq Pm - [aq] ROVO a

/EVENUE USE ONLY. DO NOT MARK IN THIS AREA.

If licer
Member? Date Joined Organization
{[%] Yes ONo Af [- /

Officers? Offi r Tile
(Yes C1 No TREAS Uk L fe

Oo you have an affida avit on file for any other jicaneee?
1 Yes Si} No __ If "Yes", list license number(s):
t

ALLEY

ari libe lll EE TK. # ___, the above-named affiant, under penalty of perjury, upon oath, depose

ind say that [ 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 | have read
and understand the foregoing and yerify that the information and statements made herein are truc and correct to the best of my

knowledge.

G5. 4h . by

Signature of Affiaht

G-LLAZ

Date

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

@ (602) 716-7801

ADOR 10327 (2/20)

Affidavit Bingo

ts bla
luntary.

incorre

t in the conduct of any game of bingo. If any informa’
affidavit will be returned to you. All information Is subject to verification. Disclosure of your Social Security Number (SSN) is

ablish positive identification for purposes of criminal background checks pursuant to A.R.S, § 5-404,

his info!

may be used to e:

License Number

Out (Smiling out Loud) |

on (check the appropriate boxes)

REVENUE USE ONLY. DO NOT (MARK IN THIS AREA

upervisor__[[] Proceed Coordinator _(] Assistant

__ BINo

1 have an affidavit c
_ELNo _if"¥

file

I j t , the above-named affiant, under penalty of perjury, upon oath, depose
j and say Ghat { will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Re

| Statutes, Title 5, Chapter 4, and the niles of the licensing authority, 1 am of good moral character and have never been convicted of

| hy misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense

tor my participation in the conduct of bingo games except as provided for by law. I hereby swear or corfirm that I have reac

going and verify that the information and statements made herein are true and correct to the best of my

and understand the for ri

knowledge.

Please mail to:
Arizona Department of Revenue

1600 W Monroe Street, Division Code 22

| Phoenix, AZ 85007 |

@ (602) 716-7801

ANOR 40327 (2/20) Print Form

Affidavit Bingo

us af

davit 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
avit vail be returned to 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.

4 OutLowd)
winery

aoa (ch
l

« the appropnale boxes):

d (

Fao] REVO

ee 1S a qualified organization, complete the following section

|Date Joined Organization

Miicers7

1 Yes

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

3@ number(s): _

. the above-named affiant, under penalty of perjury, upon oath, depose

f i
—__ABFIART S RANE 7
and say that | 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 niles of the licensing authority. 1am 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 | have read |

and understand the foregaing and verify that the information and statements made herein are true and correct to the best of my

| knowledge

i O_ 7 PALeviig al
ature of Afhant

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

@ (602) 716-7801

ADOR 10327 (2720)

Affidavit Bingo

This affidavit must be completed by each person who wis! t
affidavit will be returned to you. All Information is

v may be used to establish positive ide ntification for purposes of

slat

Pos nie (check the appropri ate boxes

[1] Manager

oO Proceed Coordinator . Risewes Assis

‘0 assist in the conduct of any game of bingo. If any information {s blank or Incorrect, the

subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information

criminal background checks pursuant to A.R.S. § 5-404,

License Number

REVENUE USE ONLY. DO NOT MARK IN THIS AREA

fant’

[
|
|

ee]

fem — ‘eal RCVD

i}
|

see is a que alified organi ation, fe complete the

Dale Joined

(C1. Yes Aine

‘a No" Yes"

following section

d Organizali

|
[ i , the above-named affiant, under penalty of perjury, upon oath, depose |
AFFIAN TS HAME ? |
ind say that I will conduct or assist in conducting all bingo gamtes in compliance with the terms of the license, Arizona Revised
| Statutes, Tide 5, Chapter 4, and the rules of the licensing authority. | am of good moral character and have never been conyicted of
| any misdemeanor involving moral turpitude or felony. I haye not and shall not receive any reward, compensation or recompe
|} lor my f ipation in the conduct of bingo games except as provided for by law. 1 hereby swear or confirm that | have read
and understand the foregoing and verify that the information and statements made herein are truc and correct to the best of my
nowle!
)
A:
)
YY oe i
1¢ A 1
nature of Affiant
Date - -
— ee ea Si

Arizon
1600 W Mo

FP 10327 (2/20)

Phoenix, AZ 85007

Please mail to:
a Department of Revenue
nroe Street, Division Code 22

® (602) 716-7801

Affidavit Bingo

formation is blank or ir ect, U

5 voluntary. This information

REVENUE USE ONLY. DO NOT MARK Ih

HIS AREA

u A, TH Boye A

=
I! licensee is aq clio
Hes C1 Nc
O : i |
f i! ather licen |
Oo It Yes". list license number(s):
! Tu a (TH B OURA the above-named afliant, under penalty of perjury, upon oath, depo:

1 will conduet or assist in vonduet

ting all bingo

in complianee with the tern:

s of the license, Arizona Revised
tutes, Tithe 5, Chapter 4. and the rules

g authority, Lan of good moral character and have never been convicted of

any misdemeanor invol

ny moral turpitude or felony. {have not and shall not receive any reward, compensation or recompens

¢ conduct of bingo games except as provided for by law. [Thereby swear or confirm that | have read
idl understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

8/1 7/ 2023

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

B (6

2) 716-7801

Affidavit

ingo

REVENUE USE ONLY. DO NOT MA

[29]

; Y he a rained affiant, under penalty of 5 pan oa
¥ that | will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Re
Statute il Chapter, and the rules of the licensing authority. Lam of good moral character and have never been cor
ny Inisdemeanor nivolving moral turpitude or Lelony, Uhave not and shall not receive any reward, compeusation or recor pen
1 ipation in miduct of bingo games exe Ss provided for by law. | hereby swear or ¢ that | have
t rl yt vl 1! the information nls made herein are true and correct to the besi of m

se mail to:

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

vé

) 716-7801