Lottery Licence Eligibility Review

Notice of Collection of Personal Information

Personal information on this form is collected under the legal authority of Municipal Act, 2001. The delegate’s information is collected and maintained for the purpose of creating a record that is available to the general public, pursuant to Section 27 of the Municipal Freedom of Information and Protection of Privacy Act. This information is collected and maintained for the purposes of preparing an agenda for Council. Questions or concerns about the collection of this information can be directed to the Clerk at 4305 Hamilton Road, Dorchester ON N0L 1G3, Phone: 519-268-7334 ext 254 or clerk@thamescentre.on.ca

Date of Application

Full Organization Name

Full Mailing Address

Organization Phone Number

Email Address

Organization Website Address

Are you Eligible for a Lottery Licence?

The Municipality of Thames Centre will review the documents submitted to determine eligibility for lottery licensing. Charitable registration with Revenue Canada or incorporation as a non-profit organization does not guarantee eligibility for lottery licensing.

Which of the following charitable classifications do the primary purposes of the organization relate to

Relief of poverty

The advancement of education

The advancement of religion

Culture and the Arts

Health and Welfare

Amateur Sports Organization

Enhancement of Youth

Enhancement of Public Safety

Community Service Organizations (Legion, Rotary, Lions, etc.)

The organization's proposed use of proceeds from lottery licences must be for charitable programs and the programs must be consistent with the charitable purposes and objects of the organization. Please indicate the specific purpose(s) or programs and associated costs you will be using lottery proceeds for and how they will benefit the residents of Thames Centre.

The organization plans to spend lottery proceeds on the following

Please provide the following documents

Incorporation Papers (Letters Patent)

Constitution and By-laws

Notification of Charitable Registration (Canada Customs and Revenue Agency), if applicable

Financial Statement for Previous Fiscal Year (audited, where applicable)

The most recent Registered Charity Information Return & Public Information Return, as submitted to Canada Customs and Revenue Agency (if applicable)

Detailed outline of all programs/services provided in the previous year and specific costs incurred in delivery

The current operating budget

The current listing of the Board of Directors with contact information (address, phone and email) and the expiry date of each person's term of office

Any other information that will assist in determining the charitable nature of the objects and purposes. (This could include the annual report, correspondence relating to it's charitable number for income-tax purposes, confirmation that it meets the reporting requirements of the Charities Accounting Act)

Which municipality?

What type of lottery?

Which municipality?

How many persons compromise your bona fide membership?

Name of Signing Officer

Title of Signing Officer

Phone Number

Email Address

Signature of Signing Officer

Clear

Name of Signing Officer

Title of Signing Officer

Phone Number

Email Address

Signature of Signing Officer

Clear