Licensee:  KOFA Ko-op

Bingo License #: 14-AZ-A



We, t
he undersigned, hereby acknowledge receipt of the amount appearing opposite our names as Bing Cash Prizes, on this date:
Name Clearly Printed Amount Won Signature












































































NUMBER OF CARDS SOLD:_____________________       ATTENDANCE:_____________________

I have personally witnessed payment in cash of the above amounts to the individuals whose signatures appear opposite such amounts.

Member responsible for Holding, Operating and Conducting Games