Return relating to a Small Society Lottery 
                                         Gambling Act 2005 – Schedule 11, Part 4 
 
The following information is required by Schedule 11, Part 4, Paragraph 39(2) of the Gambling Act 2005.  This statement must be submitted no later than three months beginning on the day on which the draw (or last	 draw) in the lottery took place.  It must be signed by two members of the Society appointed in writing for that purpose by the Society, or its governing body if applicable, and accompanied by a copy of that appointment.  All signatories must be over the age of 18 years.  
 We, being duly appointed members of the Society in compliance with the requirements of Schedule 11, Part 4, Paragraph 39(4), hereby submit the following statutory return:   

Name of Society: 	 	
Licensing Authority issued Registration number of Society: 	 	
 
Arrangements for the lottery, including: 
 
(a)	Dates on which tickets were available for  
 	sale or supply; 
 
(b)	Dates of any draw;  
 
(c)	Arrangements for prizes, including any 
 	rollover; and    
 
(d)	Details of any donated prizes:  

 
(a) 
  
(b) 
 
(c) 

(d) 
 	
Proceeds of the Lottery: 	 £ 	
Amounts deducted by the promoters of the lottery in respect of the provision of prizes (including the provision of any prizes in accordance with any rollover): 	 £ 	
Amounts deducted by the promoters of the lottery in respect of other costs incurred in organising the lottery: 	 £ 	
Any amount applied to a purpose for which the promoting Society is conducted: 	 £ 	
 
Whether any expenses in connection with the lottery were paid otherwise than by deduction from proceeds, and, if they were – 
(i)	the amount of the expenses, and  
(ii)	the sources from which they were paid 
 	  
 £ 
 £ 	
 
Name of Promoter on behalf of society 
 
Name: 
 
Address (including postcode): 

 
Daytime telephone number: 
 
Signed: 	      
 
Dated: 

Declaration and Signatures  
 
We the undersigned, being two members of the Society who are appointed in writing by the Society, or its governing body, submit this return to the Licensing Authority in accordance with the provisions of Schedule 11, Part 4, Paragraph 39 of the Gambling Act 2005. 
 
Name: 
 
Address (including postcode): 

Signed: 	      
 
Dated: 
 
    ------------------------------------------------------------------------------------------------------------------------------------------  
Name: 
 
Address (including postcode): 

Signed:  
 
Dated: 
 
PLEASE NOTE THAT IT IS AN OFFENCE UNDER SECTION 342 OF THE GAMBLING ACT 2005, TO GIVE ANY FALSE OR MISLEADING INFORMATION WITHIN THIS RETURN.

Personal Data
We have recently updated our Privacy Notice about how we use personal data provided to the Council. Further information can be found at:                 
http://www.kirklees.gov.uk/beta/information-and-data/pdf/privacy-notice-licensing-gambling-act.pdf

Kirklees Council, Licensing Department, Flint Street Depot, Flint Street, Fartown, Huddersfield HD1 6LG