State Form 48682 - Cg-Inv, Charity Gaming Ending Inventory Statement Page 2

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Number of Boxes
Serial Number of Game
Gross
Payout
Name of Distributor
Name of Game
Left
Total or Subtotal
Were any pull tabs, punchboards, or tip boards damaged, destroyed, or stolen?
Yes
No
If yes, please complete Form CG-DTL, Charity Gaming Inventory Destruction, Theft, or Loss Form.
Signature of schedule preparer
Printed name
Title
Daytime telephone
Date (month, day,
number
year)
Signature of presiding officer
Printed name
Title
Daytime telephone
Date (month, day,
number
year)
Page 2 of 2
CG-INV

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