Form Bi-1 - Organization'S Monthly Bingo Report Form - Kansas Department Of Revenue
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2ORGANIZATION’S MONTHLY BINGO REPORT
KANSAS DEPARTMENT OF REVENUE
Charitable Gaming
Docking State Office Building
915 SW Harrison Street
FOR OFFICE USE ONLY
Topeka, Kansas 66612-1588
Phone: 785-368-8222 Facsimile: 785-296-4993
Website:
Name and Address of Organization / License Number
Fiscal reporting period _______________________
Month and Year
___________________________________________________________________
DUE BY THE 25TH OF THE FOLLOWING MONTH
Name of Organization
___________________________________________________________________
o
o
Original Report
Amended Report
Change of mailing address only (Leave blank if no change)
___________________________________________________________________
License Number
SECTION A - CALL BINGO PAPER PURCHASED OR RETURNED DURING THE MONTH
(List each invoice separately. If you had no purchases or returns, then write “None.”)
Number of Faces Purchased For
Distributor’s
Invoice
Invoice
Distributor’s Name
Registration
Number
Date
Regular & Special
Progressive
Mini Games
Number
Games
Games
Totals
SECTION B - TOTAL RETAIL PRICE OF ALL INSTANT BINGO TICKETS (PULL-TABS)
$
PURCHASED OR RETURNED DURING THE MONTH
(total from reverse side)
SECTION C - TOTAL MONTHLY RECEIPTS FROM ALL CALL BINGO GAMES, INCLUDING
$
HARD CARD SALES FROM SECTION D BELOW.
(If you had no games, then write “0” or “None.”)
Number of times played this month
Average attendance per time
Total Net profit
__________
__________
_________________
Number of drawings this month
Number of times played off limits
__________
______
See Page 2 for instructions
SECTION D - SALE OF HARD CARDS AND ENFORCEMENT TAX DUE
Line 1. Enter gross receipts from re-usable or hard card sales and any admission fees charged.
$ ______________________
Line 2. Re-usable or hard cards and any admission fees charged, are subject to a 3 percent tax.
$ ______________________
Multiple the gross receipts by 3 percent.
I certify that this is a true correct and complete return.
____________________________________________________________________________________________________________
Signature
Title
Date
Make check payable to the Kansas Department of Revenue, mail completed return and check to:
BI-1
Charitable Gaming, Kansas Dept. of Revenue, 915 SW Harrison St., Topeka, KS 66612-1588.
(Rev. 2-16)
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