Form 04-833 - Games Of Chance And Contests Of Skill Permittee Annual Financial Statement - 1998 Page 7

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1998 Permittee Annual Financial Statement
Permittee Name
Permit Number
Federal EIN
Name of Operator
Operator License
Page __________ of __________
SCHEDULE D: PULL-TAB ATTACHMENT
Use a separate attachment for games sold by the permittee, vendor, or operator.
The attached games were sold by: (check one)
Y
Y
Y
Permittee
Vendor
Operator
Distributor
Game Serial
Form
Gross
Prize
Ideal
3%
Date In/
License No.
State ID Stamp Label
Number
Number
Receipts
Payout
Net
Tax
Date Out
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
Subtotal (amounts from this page)
Grand Total (include amounts from all pages)
Use additional sheets if necessary
04-833d (Revised 11/98)
Page 7

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