Form Le-21 - Quarterly Report - 2002 (Page 4 of 5) in pdf

Form Le-21 - Quarterly Report - 2002 Page 4

SCHEDULE C: LE - 21

11/2000

Quarter:______________________

License No.:___________________

Pull Tab at Bar and Club Room Summary

Org. :_________________________

1 Pull Tab Sales @ Bar/Club Room Gross Receipts (LE - 31/Line 8f):

$ ______________

2 Pull Tab Bar/Club Room Payouts (LE - 31/Line 8i):

$ _______________

3 Cost of Bar/Club Room Pull Tabs:

Vendor/Address:___________________________________

$ ______________

Vendor/Address:___________________________________

$ ______________

Vendor/Address:___________________________________

$ ______________

(report additional purchases of pull tabs on another sheet following this format)

4 Grand Total of all items listed under line 3

$ ______________

5 Miscellaneous Bar/Club Room Pull Tab Expenses:

Description:__________________________________________

$ ______________

Vendor/Address:______________________________________

(Note: All above expenses incurred during the quarter must be reported per Rule 18.5)

SCHEDULE D: LE - 21

11/2000

Raffles Summary

1 Gross Receipts

$ ______________

2 Merchandise Prizes:

a. Retail Value: $________________

b. Actual Cost: $ ______________

c. Description:________________________________________

3 Cash Prizes

$ ______________

4 Raffle Prizes Total (Line 2b + Line 3)

$ ______________

5 Expenses (tickets)

$ ______________

a. Vendor: __________________________________________

b. Address: __________________________________________

Form Le-21 - Quarterly Report - 2002 Page 4