Form 04-833 - Games Of Chance And Contests Of Skill Permittee Annual Financial Statement - 1998 Page 3

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1998 Permittee Annual Financial Statement

Permittee Name

Permit Number

Federal EIN

SCHEDULE AP: PERMITTEE ACTIVITY REPORT

List only that income received as a direct result of the games, or sale of gaming equipment.

Food booth receipts and other income should not be included in this report.

Pull-Tab Income is Reported:

As Games are Closed

As Collected

Column A

Column B

Column C

Column D

Column E

Column F

Total Gross

Cost of Prizes

Adjusted Gross

Game-Related

Gaming Activity

Receipts

Taxes

Awarded

Income

Expenses

Net Proceeds

(col. A less B & C)

(sch. C, line 29)

(col. D less E)

(from sch AP-1, line 8)

1. Bingo

2. Pull-Tabs

3. Raffles and Lotteries

4. Dog Musher's Contest

5. Fish Derbies

6. Contests of Skill

Other -

Specify

Other -

Specify

9. Sale of Equip. and Supplies

(to page 1, line 2)

(to page 1, line 6)

10. Total

Schedule BP: FAIR MARKET VALUE OF PRIZES AWARDED BY THE PERMITTEE (see instructions)

Enter the fair market value of all prizes which were donated to and awarded as a prize by your organization during the reporting period. These amounts should

not be included in column C above.

The value of donated prizes is part of the total prize limitation.

Column A

Column B

Column C

Gaming Activity

Services and

Total

Merchandise

Real Estate

Prizes

(to Sch AP-1, line 2)