Form 04-833ez - Permittee Annual Financial Statement

Alaska Department of Revenue

Dept Use Only

State of Alaska

Tax Division

FSN:

Games of Chance and Contests of Skill

PO Box 110420

Juneau, Alaska 99811-0420

2010 Permittee Annual Financial Statement - EZ

Phone 907-465-2320

AS 05.15.080(b)

Due: March 15, 2011

This form is also available on the Internet at

Federal EIN

Permit Number

Organization Name

Mailing Address

City, State, Zip

Telephone Number

Fax Number

E-mail Address

Yes

FORM ELIGIBILITY

Did your organization conduct any gaming activity other than bingo, pull-tabs or raffles and lotteries? …………………………………………….

Were the total gross receipts from all gaming activities $20,000 or more? …………………………………………………………………………….

Did you contract with an operator or vendor at any time during the year? ……………………………………………………………………………..

Were you a member of an MBP at any time during the year? ……………………………………………………………………………………………..

Do not use this form if:

A. You answered "Yes" to any of the questions above, or

B. Any of your gaming activities had a negative adjusted gross income.

SUMMARY INFORMATION

1. Total adjusted gross income from page 2, Schedule AP, line 4 …………………………………………………………………1

2. Total net proceeds from page 2, Schedule AP, line 6 …………………………………………………………………………… 2

GAMING ACCOUNT BALANCE

3. Prior year balance of Games of Chance and Skill checking account ………………………………………………………… 3

4. Net Proceeds (Page 1, line 2) …………………………………………………………………………………………………..… 4

5. Interest earned on Games of Chance and Skill checking account ……………………………………………………………. 5

6. Other Deposits and Increases (See Instructions) ………………………………………………………………………………. 6

7. Total (add lines 4, 5, and 6) …………………………………………………………………………………………………..…… 7

8. Total Donations of net proceeds (Page 2, Schedule E, Total Donations) ……………………………………………………. 8

9. Other Disbursements and Reductions (See Instructions) ……………………………………………………………………… 9

10. Total reductions to checking account (add lines 8 and 9) ……………………………………………………………………… 10

11. Year-end balance of Games of Chance and Skill checking account (add lines 3 and 7, subtract line 10) …………………11

We declare under penalty of unsworn falsification, that we have examined this report, including accompanying schedules and statements,

and to the best of our knowledge and belief, it is true and complete.

Member in Charge or Agent Signature / Date

Printed Name

President or Treasurer Signature / Date

Printed Name

Paid Preparer's Signature / Date

Printed Name

Paid Preparer's Firm Name

Paid Preparer's Firm Address, City, State, Zip

Attach a copy of your December 31, 2009 and December 31, 2010,

DEPT USE ONLY

PMD:

bank statements and bank reconciliations.

Form 04-833EZ (Rev. 12/10) Page 1

Form 04-833ez - Permittee Annual Financial Statement - 2010

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