Form 04-843 - Operator Quarterly Report - 2002
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5Alaska Department of Revenue
Report Period (check one)
State of Alaska
Tax Division
January -March
April - June
Games of Chance and Contests of Skill
PO Box 110420
Juneau, Alaska 99811-0420
2002 Operator Quarterly Report
October - December
July - September
Phone 907.465.2320
AS 05.15.083(a)
Fax 907.465.3098
Due Date: The last business day of the month following
each calendar quarter in which an activity was conducted.
This form is also available on the Internet at
Federal EIN or SSN
License Number
Operator Name / dba
Page _____ of _____
Mailing Address
City, State, Zip
Contact Person
Phone Number
Fax Number
E-mail Address
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Complete columns A through G for each permittee for whom
Gross Receipts
Taxes
Prizes
Adjusted Gross
Game Related
Net Proceeds
Net Proceeds
gaming activities were conducted during the reporting period.
Income
Expenses
Paid
(from Schedule A,
(from Schedule A,
(from Schedule A,
(from Schedule A,
(from Schedule A,
(from Schedule A,
(from Schedule A,
Permit No.
Permittee Name
line 1, column I)
line 2, column I)
line 3, column I)
line 4, column I)
line 5, column I)
line 6, column I)
line 7, column I)
TOTALS …………………
TOTAL NET PROCEEDS PAID TO ALL PERMITTEES …………………
I declare, under penalty of unsworn falsification, that I have examined this report,
including accompanying schedules and statements, and to the best of my knowlege and belief, it is true and complete.
Operator or Agent Signature / Date
Printed Name
X
Paid Preparer's Signature / Date
Printed Name
X
Firm Name
Firm Address, City, State, Zip
use additional
DEPT USE ONLY
Attach a completed copy of the Federal and State Quarterly Payroll Reports
PMD:
sheets
for this reporting period.
if necessary
Form 04-843 (Rev 10/01) Page 1
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