Form 04-839 - Games Of Chance And Contests Of Skill Pull-Tab Distributor Monthly Report Page 3
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4Pull-Tab Distributor Monthly Report
Business Name
Federal EIN or SSN
Gaming License Number
Month
Year
SCHEDULE B - TAX PAID RETURNS AND CREDITS
Originally Reported
Originally Distributed To:
Pull-Tab
Reason for
Game Name /
Serial
"Ideal Net"
Month
Page
Permit or License
Purchaser's Name
Identification Stamp Label
Return or Credit
Form Number
Number
Per Series
SUBTOTAL
"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
TOTAL
were sold at face value, less the prizes to be awarded for that series.
04-839b (Rev. 12/07) Page 3
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Parent category: Financial