VILLAGE OF LIBERTYVILLE

Application:
License to Conduct a Raffle
Return Completed Form To:
Village of Libertyville
118 W. Cook Avenue
Libertyville, IL  60048
Attn: Village Administrator’s Office

Raffle License Fee:    	$60.00
	License to Conduct a Raffle	
Organization Information
must be a 501(c)3 for a minimum of 5 years	
Name & Address of Organization		

Character of Organization & Date of Formation		
Officers Information	
First, Middle Initial, Last Name
Address DOB		

First, Middle Initial, Last Name
Address DOB		

First, Middle Initial, Last Name
Address DOB		

First, Middle Initial, Last Name
Address DOB		

First, Middle Initial, Last Name
Address DOB		

Raffle Manager Information
Must live in corporate Village limits of Libertyville	
First, Middle Initial, Last Name
Address
DOB
Phone Number E-mail		

		

Raffle Information (Please attach additional pages if more space is needed)	
Date(s) of Raffle		
		
Date(s) of Ticket Sales		
		
Proposed price for each ticket sold		Total Number of Chances to be Sold	
			
Location where chances will be		
sold		
		
Location where raffle will take		
place		
		
Type of raffle		
		
Objects to be raffled		
		
Maximum retail value of each		Total retail value of all prizes	
prize(s)			

Attestations	Agree
(Initial below)	
Bond Waiver Request
The Village Administrator or his/her designated representative is authorized to waive the requirement for a bond by including a waiver provision in the license issued, provided that by a unanimous vote of the members of the licensed organization such a waiver is requested. Such a request does not guarantee that a waiver will be granted by the Village of Libertyville; however, your organization may request a waiver of the bonding requirements.		
I	the designated raffle manager to hereby consent that I have not had a raffle		
license revoked by any governing body, nor been convicted of a felony and meet all of the requirements to act in the capacity of the raffle manager for	_____organization.		
We hereby attest that	organization is a bona fide religious, charitable, labor,		
fraternal, educational, or veteran organization which operates without profit to its members and which has been in existence continuously for a period of five (5) years immediately before making this application for a license, and which had during that entire five (5) year period had a bona fide membership engaged in carrying out its objectives as described on the attached raffle application.		
Pursuant to the Village Code of the Village of Libertyville, all raffle tickets, which are sold off the premise upon which the raffle is to be held must contain the license number issued by the Village. If tickets are only sold the premises the day on which raffle drawing is held, the license issued by the Village must be displayed. The applicant agrees to conform to all Village code requirements. The applicant hereby agrees not to violate any of the laws of the State of Illinois or the United States, nor any ordinances of the Village of Libertyville in the conduct of the raffle(s). Further, applicant agrees not to allow gambling devises or gambling on the premises where the raffle(s) will be held. Applicant agrees to maintain all financial records required by the Raffle Control Ordinance and to report monthly to its membership and to the Village of Libertyville, its gross receipts, expenses, and net proceeds from raffles, and the distribution of net proceeds itemized as to payee, purpose, amount and date of payment.		

Signed:	(President)	(Secretary)
	(Raffle Manager) Date:	___________________.
Sworn and subscribed before me this:	(day) of	, 2022.
Notary:	(Seal)