Video Gaming Report
North Carolina Department of Revenue
FEIN or SSN
Owner’s Name and Business Address
Report for Quarter Ending
Report Completed By
Contact Person (If different from owner)
Phone Number for Contact Person
Agent of Owner
Use this form to report to the Department of Revenue the operations of video gaming machines that are subject to registration with the local
sheriff. The law, in G.S. 14-306.1(j), requires the owner of each machine or the owner’s agent to file a quarterly report with the Department
listing the gross receipts from the machines and the other specified information. If you have questions about how to complete this form, call
the Tax Research Division at 919-733-4548.
Submit only one copy of the front page of Form TR-100. Part 1 contains the summary information for all entries in Part 3. You may submit
as many pages of Part 3 (the reverse page of Form TR-100) as you need to account for all machines (counting each machine only once,
regardless of the number of locations it occupied during the quarter), but in Part 1 enter only the total number of all machines included in the
report, the total gross receipts from all machines, and the total value of all prizes awarded.
In Part 3, use the cabinet serial number for each machine registered with the sheriff. Part 3 allows an entry for up to three machines at each
location. If you had more than three machines at a location during the same reporting period because a machine was not at the location for
the entire period, make a second entry for the same location and enter the additional machines. If a machine was out of service for a period,
write “Out of Service” in the space for the address, enter the dates the machine was not in service in the space for Dates at Location, and put
the county where the machines were located. You may attach a spreadsheet in the format of Part 3 in lieu of completing Part 3 by hand.
This report is due on or before the 15th day of the month after the end of each calendar quarter. The postmark determines if the report
is filed on time. Failure to file a timely report on a machine or filing a report that contains a material false statement about a machine
makes the machine subject to seizure under G.S. 14-298.
Summary of Video Gaming Machine Activity
1. Number of Machines Reported in Part 3
2. Total Gross Receipts from Machines
3. Total Value of Prizes Awarded
Part 2. Authorized Signatures
Place Notary Seal Below
Owner or Agent
I swear or affirm that, to the best of my knowledge, this report is accurate and complete.
Sworn and subscribed before me on
Notary Public Signature
Date My Commission Expires
MAIL TO: North Carolina Department of Revenue, Tax Research Division, PO Box 25000, Raleigh, North Carolina 27640-0003