Form 04-839 - Games Of Chance And Contests Of Skill Pull-Tab Distributor Monthly Report Page 2
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4Pull-Tab Distributor Monthly Report
Business Name
Federal EIN or SSN
Gaming License Number
Month
Year
Purchaser Name
Purchaser Permit or License Number
Purchaser is (check one)
□
□
Permittee
Operator
SCHEDULE A - DEALS DISTRIBUTED TO PERMITTEE OR OPERATOR
Date
Pull-Tab
Serial
Game Name /
Ticket
Ticket
Gross
"Ideal Net"
3%
Sold
Manufacturer
Identification Stamp Label
Number
Form Number
Price
Count
Payout
Per Series
Tax
SUBTOTAL
TOTAL
"Ideal Net" means an amount equal to the total amount of receipts that would be received if every individual
pull-tab ticket in a series were sold at face value, less the prizes to be awarded for that series.
04-839a (Rev. 12/07) Page 2
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Parent category: Financial