Cg-Inv State Form 48682 - Charity Gaming Ending Inventory Statement - 2005 Page 2
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1
2Serial Number
Name of
Number of
Name of Game
Of Game
Manufacturer/Distributor
Boxes Remaining
Total or Subtotal
Were any pull tabs, punchboards, or tip boards damaged, destroyed, or stolen?
Yes
No
If yes, please fill out the Damaged/Stolen Inventory section below:
(Attach additional sheets necessary.)
Damaged/Stolen Inventory
Date:
Reason:
Number of boxes/ bags, etc:
Gross income of boxes in question:
Serial numbers of all boxes:
Was an insurance claim filed?
If yes, date and agency name:
Was a police report filed?
If yes, date and agency name:
Did a representative of IDOR witness the destruction of PPT's?
If yes, date and representative's name:
Under penalty of perjury, I have examined this schedule and, to the best of my knowledge and belief, it is true, complete and correct.
Signature of schedule preparer
Date
Attach to Schedule CG-8. NOTE: Please make copies of this schedule if more are needed.
CG-INV (2)
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Parent category: Financial