Form 04-828 - Games Of Chance And Contests Of Skill - Permittee Quarterly Report - 2008 Page 2
ADVERTISEMENT
1
22008 Permittee Quarterly Report
Permit Number
Permittee Name
License Number
Operator/Vendor Name/dba
SCHEDULE D: PULL-TAB ATTACHMENT
Use a separate attachment for games sold by the permittee, vendor, or operator.
The attached games were sold by: (check one)
Quarter (check one)
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Page _____ of _____
Permittee
Vendor
Operator
Distributor
Game Serial
Form
Gross
Prize
Ideal
3%
Date In/
License No.
State ID Stamp Label
Number
Number
Receipts
Payout
Net
Tax
Date Out
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
Subtotal (amounts from this page) …………………………
Use additional
sheets if necessary.
Grand Total (include amounts from all pages) …………………………
Form 04-828 Rev. 11/07 Page 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial