Raffle Information Sheet Template - Free Download | Page 3
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RETURNED PRIZES
Did any prize winner donate his/her prize back to the raffle licensee Yes_____ No_____
If yes, name the prize winner and indicate the disposition of the donated prize:
UNCLAIMED PRIZES List any unclaimed prizes here. All unclaimed prizes must be held for a period of one year. See OAR 137-25-290(5).
Prize:
Winning Ticket Stub Number: Retail Value: $
Winner’s Name/Address if known:
Did you attempt to contact winner Yes_____ No_____
Prize:
Winning Ticket Stub Number: Retail Value: $
Winner’s Name/Address if known:
Did you attempt to contact winner Yes_____ No_____
Prize:
Winning Ticket Stub Number: Retail Value: $
Winner’s Name/Address if known:
Did you attempt to contact winner Yes_____ No_____
Prize:
Winning Ticket Stub Number: Retail Value: $
Winner’s Name/Address if known:
Did you attempt to contact winner Yes_____ No_____
Prize:
Winning Ticket Stub Number: Retail Value: $
Winner’s Name/Address if known:
Did you attempt to contact winner Yes_____ No_____
TICKET STUBS
You must retain the winning ticket stubs from each raffle, regardless of the value of the prize. Attach
the winning stubs to this sheet.
CERTIFICATION
I certify that the raffle described herein was conducted in compliance with the administrative rules
governing the conduct of raffles, OAR 137-25-200 et. seq. I further certify that the information
contained herein is true and accurate.
Responsible Official’s Signature:
Title:
Date:
source: unitedwaypoco.org
