Form 04-844 - Operator Quarterly Report - 2007
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5Alaska Department of Revenue
DEPT USE ONLY
State of Alaska
Tax Division, Gaming Group
GSN:
Games of Chance and Contests of Skill
PO Box 110420
Juneau, Alaska 99811-0420
2007 Operator Annual Report
Phone 907-465-2320
AS 05.15.083(b)
Due Date: February 28, 2008
This form is also available on the Internet at
Federal EIN or SSN
License Number
Operator Name / dba
Page _____ of _____
Mailing Address
City, State, Zip
Contact Person
Phone Number
Fax Number
E-mail Address
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Complete columns A through G for each permittee for whom
Gross Receipts
Taxes
Prizes
Adjusted Gross
Game Related
Net Proceeds
Net Proceeds
gaming activities were conducted during the reporting period.
Income
Expenses
Paid
(from Schedule A,
(from Schedule A,
(from Schedule A,
(from Schedule A,
(from Schedule A,
(from Schedule A,
(from Schedule A,
Permit No.
Permittee Name
line 1, column I)
line 2, column I)
line 3, column I)
line 4, column I)
line 5, column I)
line 6, column I)
line 7, column I)
TOTALS ………………….
TOTAL NET PROCEEDS PAID TO ALL PERMITTEES …………………
I declare, under penalty of unsworn falsification, that I have examined this report, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true and complete.
Operator or Agent Signature / Date
Printed Name
X
Paid Preparer's Signature / Date
Printed Name
X
Firm Name
Firm Address, City, State, Zip
use additional
DEPT USE ONLY
PMD:
Attach a completed copy of the Internal Revenue Service Form 940 and a W-2
sheets
for each person employed by the operator in 2007.
if necessary
Form 04-844 (Rev. 12/07) Page 1
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