Form Wv/bgo-3 - Super, Annual, Limited & State Fair Bingo Financial Report
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1
2WEST VIRGINIA STATE TAX DEPARTMENT
WV/BGO-3
DUE 30 DAYS AFTER EXPIRATION
CHARITABLE BINGO/RAFFLE UNIT
REV. 02/05
PO BOX 1143
CHARLESTON WV 25324-1143
SUPER, ANNUAL, LIMITED & STATE FAIR BINGO FINANCIAL REPORT
WV IDENTIFICATION NUMBER, NAME, ADDRESS & TELEPHONE NUMBER
REPORT PERIOD
TYPE OF LICENSE:
SUPER
REGULAR ANNUAL
LIMITED
STATE FAIR
(Please circle one)
LICENSE NUMBER:
NUMBER OF OCCASIONS THIS PERIOD:
RECEIPTS: For Reporting Period
1
ADMISSION OR RECEIPTS
$
2
RECEIPTS FROM CARDS
$
3
SALES OF SUPPLIES
$
4
DONATED PRIZES (Market Value)
$
4a
TOTAL RECEIPTS FROM SUPER BINGO
$
OCCASIONS FOR THE SAME PERIOD OF THIS
RETURN
4b
CHILD CARE SERVICES
$
5
OTHER RECEIPTS (Attach Itemized Sheet)
$
6
TOTAL RECEIPTS (Add Lines 1 through 5)
$
PRIZE
7
CASH OR CHECK
$
8
MERCHANDISE—CASH VALUE AT TIME OF
$
PURCHASE
9
DONATED PRIZES (VALUE)
$
9a
TOTAL PRIZES FROM SUPER BINGO
$
OCCASIONS FOR THE SAME PERIOD OF THIS
RETURN
10
OTHER PRIZES (Door Prizes, Winner Take All,
$
Penny Games)
11
TOTAL ALL PRIZES (Add Lines 7 through 10)
$
EXPENSES
12
RENTAL
$
13
ADVERTISING
$
14
CUSTODIAL SERVICE
$
15
EQUIPMENT & SUPPLIES
$
16
SECURITY PERSONNEL
$
16a
TOTAL EXPENSES FROM SUPER BINGO
$
OCCASIONS FOR THE SAME PERIOD OF THIS
RETURN
16b
SALARIES FOR BINGO OPERATORS (Attach List)
$
17
OTHER (Explain)
$
18
TOTAL BINGO EXPENSES (Add Lines 12 through 17)
$
19
NET PROFIT (Loss) (Subtract Lines 11 and 18 from 6)
$
NAME OF BANK AND BINGO CHECKING ACCOUNT NUMBER:
20
BEGINNING BALANCE (UNEXPENDED BALANCE AT END OF LAST PERIOD)
$
21
NET PROFIT (loss) FOR THIS PERIOD (Line 19)
$
22
OTHER DEPOSITS OR ADJUSTMENTS IN SPECIAL BINGO ACCOUNT:
$
Explain:______________________________________________________
23
NAMES OF ORGANIZATIONS AND AMOUNTS CONTRIBUTED THIS PERIOD:
$
(Attach Itemized Sheet)
TOTAL PAID TO ORGANIZATIONS
24
ENDING UNEXPENDED BALANCE (20+21+/-22+/-23=24) (Must match
$
checkbook)
CONCESSIONS
CONCESSION OPERATOR:
Receipts:
_______________________
Expenses:
_______________________
Net Profit (Loss)
_______________________
REVERSE SIDE: Complete detailed check listing and SIGN RETURN WHERE INDICATED.
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