Form Le-21 - Quarterly Report - 2002
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5LE - 21: QUARTERLY REPORT
8/2002
Office of the Secretary of State
1560 Broadway - Suite 200
FINANCIAL STATEMENT: BINGO/RAFFLES
Denver, Colorado 80202
1. License Number
COMPLETE EVEN IF YOU HAD
NO ACTIVITY THIS QUARTER
2. Organization
3. Mailing Address
4. City, State, Zip
5. REPORT FILING DATE: (Check one)
st
nd
rd
th
1
Qtr/April 30____ 2
Qtr/July 31____ 3
Qtr/October 31____ 4
Qtr/January 31_____
_
6. BANK ACCOUNT Checking #_________________ Bank Name______________________
INFORMATION
Savings #__________________ Bank Name______________________
IF NO ACTIVITIES HELD THIS QUARTER, OMIT 7-15 AND ATTACH SCHEDULE A ONLY
7. Bingo: Circle day(s) of week and enter time(s)
Sun____pm Mon____pm Tue____pm Wed____pm Th____pm Fri____pm Sat____pm
____
am
____am
____am
____am
____am
____am
____am
Total # of bingo occasions held during quarter: __________
8. Pull Tabs @ Bingo:
(Circle one)
Yes
No
) S M T W T F S - # days during qtr: _____
9. Pull Tabs @ Club:
(Circle day(s) of week on sale
10. Raffles: Date(s)_________________________________
# held during quarter: _______
CALCULATION OF FEES:
11. Bingo Gross Receipts (Schedule B/ Line 1 + Schedule E/ Line 1)
$________________
$________________
12. Pull Tab Gross Receipts (Sch B/ Line 2 + Sch C/ Line 1 + Sch E/ Line [s] 3 & 5)
13. Raffle Gross Receipts (Schedule D/ Line 1)
$________________
14. Total Receipts (Line 11 + Line 12 + Line 13)
$________________
15.
$________________
Total Fee: If Line 14 is less than $100,000, Fee = Line 14 x .003 (.3%)
$________________
If Line 14 is $100,000 or more, Fee = Line 14 x .004 (.4%)
16. VERIFICATION STATEMENT:
This statement is made under penalty of perjury and does NOT need to be notarized.
I, __________________________________(name of person filing report), solemnly affirm under
penalty of perjury, as defined in section 18-8-503, Colorado Revised Statutes and punishable by
law, that I am ____________________________(title) of the above named organization; that my
address is ____________________________________________________, that my work phone
number is _________________, that my home phone number is _________________. I further
affirm that I am fully and duly authorized to sign and file this report, that I have read the report
and know its contents, and that it is true and complete.
Date:_____________________
_______________________________________
(Signature of person filing report)
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