Form Wv/bgo-3 - Super, Annual, Limited & State Fair Bingo Financial Report Page 2
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2LISTING OF CHECKS PAID OUT OF BINGO CHECKING ACCOUNT
USE ADDITIONAL SHEETS IF NECESSARY *PLEASE NOTE: ALL CHECKS PAID OUT OF BINGO ACCOUNT
MUST BE LISTED BEFORE RETURN CAN BE ACCEPTED
CHECK
DATE
PAYEE
PURPOSE OF CHECK
DOLLAR
NUMBER
AMOUNT
THE FINANCIAL RETURN MUST BE CERTIFIED BY A CERTIFIED PUBLIC ACCOUNTANT OR BY A LICENSED
PUBLIC ACCOUNTANT IF LINE 6 (TOTAL RECEIPTS) EXCEEDS $50,000.
I, _________________________________________, as an authorized representative of _________________________
________________________________, certify or affirm that the statement and items entered herein and attached are
true and correct to the best of my knowledge.
__________________________
__________________________________
________________________
Date
Signature
Title
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