STATE OF WEST VIRGINIA 
        State Tax Department, Charitable Bingo/Raffle Unit
        P.O. Box 1143
        Charleston, WV 25324-1143

        Name

        Address                                                                                  Account #:

        City                                                            State                 Zip

WV/RAF-3
rtL179 v.10-Web ANNUAL, LIMITED & STATE FAIR RAFFLE FINANCIAL REPORT
Taxpayers required to file electronically will no longer receive returns for the tax types subject to the
        mandatory requirement by mail.  Please visit www.tax.wv.gov for additional information.
                         PLEASE USE BLUE OR BLACK INK ON ALL FORMS
Report Period:                to                         Due 30 days after expiration of license           Check if Annual Report

                              CALCULATION OF ENDING BALANCE
1. Total Gross Proceeds (From Schedule A Line 4)
                                                                                                                                 .
2. Total All Prizes (From Schedule B Line 5)
                                                                                                                                 .
3.  Total Raffle Expenses (From Schedule C Line 9)
                                                                                                                                 .
4. Net Profit (Loss) for this Period (Line 1 minus Line 2 and Line 3)
                                                                                                                                 .
5.  Beginning Balance (Unexpended Balance at End of Previous Year)
                                                                                                                                 .
6.  Other Raffle Deposits
                                                                                                                                 .
7. Adjustments in Raffle Account (Attach Explanation)
                                                                                                                                 .
8.  Monies Transferred to Bingo to Cover Losses
                                                                                                                                 .
9.  Amounts Contributed to Organizations this Year
                                                                                                                                 .
10. Ending Unexpended Balance (Line 4 plus Line 5 plus Line 6 plus Line 7 minus Line 8 minus Line 9)
                                                                                                                                 .
11. Year End Inventory (Dollar amount paid for games on hand)
                                                                                                                                 .
12. Percentage Used to Pro-Rate Expenses (If Applicable)
                                                                                                                                 .
                NAME OF BANK AND RAFFLE CHECKING ACCOUNT NUMBER
NAME OF BANK                                                              RAFFLE CHECKING ACCOUNT NUMBER

                                                         CONCESSIONS
    CONCESSION OPERATOR:
1.  Receipts
                                                                                                                                 .
2.  Expenses
                                                                                                                                 .
3.  Net Profit (Loss) (Line 1 minus Line 2)
                                                                                                                                 .
                                           Complete Page 3 detailed check listing

                MAIL TO:  WEST VIRGINIA STATE TAX DEPARTMENT
                Charitable Bingo/Raffle Unit
                P.O. Box 1143, Charleston, WV  25324-1143
                FOR ASSISTANCE CALL  (304) 558-8683
                For more information visit our web site at: www.tax.wv.gov
                File online at https://mytaxes.wvtax.gov                                            O     1     7     0     8     0     9     0     1     W

WV/RAF-3
rtL179 v.10-Web  ANNUAL, LIMITED & STATE FAIR RAFFLE FINANCIAL REPORT

                            PLEASE USE BLUE OR BLACK INK ON ALL FORMS

                                        SCHEDULE A - GROSS PROCEEDS
1. Sale of Raffle Tickets
                                                                                                                         .
2. Donated Prizes (Value)
                                                                                                                         .
3. Other Proceeds
                                                                                                                         .
4. Total Gross Proceeds (Add lines 1 through 3) Enter here and on Page 1 Line 1
                                                                                                                         .

                                        SCHEDULE B - PRIZE PAYOUTS
1. Cash or Check
                                                                                                                         .
2. Merchandise (Value)
                                                                                                                         .
3. Donated Prizes (Value)
                                                                                                                         .
4. Door Prizes
                                                                                                                         .
5. Total All Prizes (Add Lines 1 Through 4) Enter here and on Page 1 Line 2
                                                                                                                         .

                                        SCHEDULE C - RAFFLE EXPENSES
1. Rental
                                                                                                                         .
2. Salaries & Related Payroll Taxes
                                                                                                                         .
3. Bad Checks
                                                                                                                         .
4. Utilities
                                                                                                                         .
5. Raffle Games
                                                                                                                         .
6. Custodial, Security, Personnel, Child
                                                                                                                         .
7. Maintenance & Repairs
                                                                                                                         .
8. Other (License Fee, Etc…)
                                                                                                                         .
9. Total Expenses (Add Lines 1 Through 8) Enter here and on Page 1 Line 3
                                                                                                                         .

                                        AGREEMENT
THE FINANCIAL RETURN MUST BE CERTIFIED BY A CERTIFIED PUBLIC ACCOUNTANT OR BY A LICENSED PUBLIC ACCOUNTANT
IF SCHEDULE A LINE 4 (TOTAL GROSS RECEIPTS) EXCEEDS $50,000.

I,                                      , AS AN AUTHORIZED REPRESENTATIVE OF
CERTIFY OR AFFIRM THAT THE STATEMENTS AND ITEMS ENTERED HEREIN AND ATTACHED HERETO ARE TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE.
                (Name - Type or Print)                                  (Signature)                       (Date)

                 (Telephone Number)                                     (Email Address)

                                                            Page 2 of 4                O     1     7     0     8     0     9     0     2     W

WV/RAF-3
rtL179 v.10-Web ANNUAL, LIMITED & STATE FAIR RAFFLE FINANCIAL REPORT

Account #:

Name
                     PLEASE USE BLUE OR BLACK INK ON ALL FORMS

                LISTING OF CHECKS PAID OUT OF RAFFLE CHECKING ACCOUNT
        USE ADDITIONAL SHEETS IF NECESSARY *PLEASE NOTE: ALL CHECKS PAID OUT OF RAFFLE ACCOUNT
                     MUST BE LISTED BEFORE RETURN CAN BE ACCEPTED
    CHECK       DATE PAYEE            PURPOSE OF CHECK               DOLLAR
NUMBER                                                               AMOUNT

                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                                                                     .
                           Page 3 of 4

WV/RAF-3
rtL179 v.10-Web ANNUAL, LIMITED & STATE FAIR RAFFLE FINANCIAL REPORT

                PLEASE USE BLUE OR BLACK INK ON ALL FORMS

                THIS SCHEDULE MUST BE FILED WITH ALL RAFFLE FINANCIAL REPORTS
                     SCHEDULE 1
                LIST ALL WINNERS OVER $100.00 AT EACH RAFFLE OCCASION
                                SOCIAL                               DOLLAR
DATE            NAME ADDRESS    SECURITY                             AMOUNT
WON                             NUMBER                                       WON

                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .
                                                                                .

                     Page 4 of 4