Form Le-21 - Quarterly Report - 2002 Page 3
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5Quarter:_______________________
SCHEDULE B: LE - 21
11/2000
License No.:___________________
Bingo Occasion Summary
Org.:_________________________
Total Number of Players This Quarter (LE - 32 /Line 25)_____________
1 Bingo Gross Receipts (adjusted) (LE - 32 /Line 15c)
$________________
2 Pull Tab Sales @ Bingo Occasions Gross Receipts (LE - 31/Line 8f)
$________________
3 Bingo cash payouts (LE - 32 /Line 14a)
$________________
4 Merchandise payouts on bingo: actual cost (LE - 32 /Line 14b)
$________________
a. Retail Value (LE - 32 /Line 14c): $ __________________
5 Pull Tab payouts @ Bingo Occasions (LE - 31/Line 8i)
$________________
6 Rent
a. Landlord #1 Name: ______________________________
$________________
Address: ______________________________________
b. Landlord #2 Name: ______________________________
$________________
Address: ______________________________________
7 Security a. Security #1 Name:___________________________
$________________
Address:___________________________________
b. Security #2 Name:___________________________
$________________
Address:___________________________________
8 Bookkeeping Name(s) & _______________________________
Address(es):_______________________________
$ _______________
9 Janitorial
Name(s) &
_______________________________
Address(es): _______________________________
$ _______________
10 Supplies and other costs:
Bingo Supplies Only:
a. Description:_____________________________ Total Expense
$________________
Vendor: ________________________________
b. Description:__ ___________________________ Total Expense
$________________
Vendor: ________________________________
Pulltab Supplies at Bingo Occasions Only:
a. Vendor:________________________________
Total Expense
$_______________
b. Vendor:________________________________
Total Expense
$_______________
(report additional purchases of bingo and/or pulltab supplies on another sheet following this format)
____________________________________________________________________________
11 Grand Total of all items listed under line 10
$_______________
(Note: All above expenses incurred during the quarter must be reported per Rule 18.5)
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