Form 04-833ez - Permittee Annual Financial Statement - 2010 Page 2
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32010 Permittee Annual Financial Statement - EZ
Permit Number
Permittee Name
Page _____ of _____
SCHEDULE AP: PERMITTEE ACTIVITY REPORT
Column A
Column B
Column C
Column D
(1)
(1)
Description
Raffles
Total
Bingo
Pull-Tabs
1. Gross Receipts
2. Taxes
3. Cost of Prizes
(2)
4. Adjusted Gross Income
(t
1 li
6)
5. TOTAL EXPENSES
(3)
6. NET PROCEEDS
(1) Accrual accounting required
(2) Subtract lines 2 and 3 from line 1. Enter Total Adjusted Gross Income on page 1 line 1
(3) Subtract line 5 line from line 4. Enter Total Net Proceeds on page 1 line 2
SCHEDULE C: GAME-RELATED EXPENSES
(If adjusted gross income for any activity is negative, stop here. Use the long form)
1. Rental of Facility
2. Other Facility Costs
3. Contract / Professional Services
4. Accounting
5. Wages
6. Payroll Taxes
7. Pull-Tab Tax Paid
Cost of Bingo Cards
8.
and Pull-tab Games
9. Advertising
10. Equipment Purchases
11. Building Depreciation
12. Door Prizes
13. Other Expenses
14. TOTAL EXPENSES
SCHEDULE E: DONATIONS OF NET PROCEEDS
RECIPIENT
PURPOSE
DATE
CHECK NO
AMOUNT
Subtotal (amounts from this page) ………………………
Use additional sheets if necessary.
Total Donations (include amounts from all pages) …………
Form 04-833EZ (Rev. 12/10) Page 2
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Parent category: Financial