Form 51689 - Use Of Proceeds: Calculation And Distribution Listing (Page 2 of 2) in pdf

Form 51689 - Use Of Proceeds: Calculation And Distribution Listing Page 2

8. List below all distrubutions made from the organization’s charity gaming account (during the accounting period listed on line 4) that

qualify as use of proceeds (all distributions made as use of proceeds must be written from the organization’s charity gaming

account). List specific information, such as: high school PTO (list Federal ID#); building fund (list account number); scholarship

fund (list account number); mortgage payment (list account number); donation to other charities (list Federal ID#); etc. Attach

additional pages if necessary.

List Distributions that Qualify as Use of Proceeds

Federal ID#, loan #,

Distribution

Identify Distribution from Charity Gaming Account

Taxpayer ID#, acct. #

Date

Amount

Add net distribution amounts from any additional pages and enter total here ...............................................

Total amount distributed which qualifies as use of proceeds. Add all amounts in

the Distribution Amount column and enter here ........................................................................................... 8 $

We certify under penalty of perjury that there are no misreprensations or falsifications in the information stated on this schedule.

We understand false or misleading information can cause the revocation of future license(s).

Signature of Current Officer

Date

Signature of Current Officer

Date

Form 51689 - Use Of Proceeds: Calculation And Distribution Listing Page 2