Gambling Tax Return Form

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CITY OF UNIVERSITY PLACE
COMMUNITY SERVICES DEPARTMENT/FINANCE DIVISION
3715 BRIDGEPORT WAY WEST, B1
Phone (253)-566-5656
UNIVERSITY PLACE WA 98466-4456
Fax
(253)-566-5658
GAMBLING TAX RETURN
Month of ____________, 20____
Due 15th of ___________, 20 ____
Gross receipts from gambling activities for the current calendar year:
Bingo
$_______________
Punch Boards
$______________
Raffles
$_______________
Pull Tabs
$______________
Amusement Games
$_______________
Card Playing
$______________
Complete this section for the month’s net receipts as defined in amended Ordinance No. 17, from the activities listed
below:
CLASS
NET RECEIPTS
TAX RATE
TAX DUE
Bingo
$______________
5%
$______________
Raffles
$______________
5%
$______________
Amusement Games
$_____________
2%
$______________
Complete this section for the month’s gross receipts from the activities listed below:
CLASS
GROSS RECEIPTS
TAX RATE
TAX DUE
Punch Boards
$_______________
5%
$_____________
Pull Tabs
$_______________
5%
$_____________
Card Playing
$_______________
20%
$_____________
TOTAL TAX
$___________
PENALTY AND INTEREST ASSESSED
$___________
TOTAL TAX, PENALTY AND INTEREST
$__ _________
IF FINAL RETURN, THE DATE THE ACTIVITY WAS DISCONTINUED:
____________
I declare under the penalties of perjury that this return (including any accompanying schedules) has been examined
by me and to the best of my knowledge and belief is a true, correct and complete return.
Dated this _______ day of __________________, 20_______
Firm Name
________________________________________________________________
Authorized by
________________________________________________________________
Office or Title
________________________________________________________________
Phone Number
________________________________________________________________
ATTACH A COPY OF YOUR WASHINGTON STATE GAMBLING COMMISSION MONTHLY INCOME
SUMMARY AND QUARTERLY RETURN, IF THE END OF THE QUARTER.
Returns may be submitted with payment either by mail at the address listed above or in person at City Hall Administration
located at 3715 Bridgeport Way West, Ste B1 in Windmill Village.
M:\Tax Revenue\Gambling Tax\Gambling Tax Return-For Profit.doc
04/13/04 9:36 AM

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