Form 04-844 - Operator Annual Report - 2009 Page 4
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52009 Operator Annual Report
Permit Number
Permittee Name
License Number Operator Name / dba
Page _____ of _____
SCHEDULE D: PULL-TAB ATTACHMENT
Use this form only for games not included in the Operator Quarterly Reports.
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
IN
OUT
IN
OUT
Subtotal (amounts from this page) …………………………
Use additional
sheets if necessary.
Grand Total (include amounts from all pages) …………………………
Form 04-844 (Rev. 10/09) Page 4
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