Form Cg-21 - Indiana Annual Bingo License Gross Receipts Report Page 2
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1
2
3Schedule 1:
Enter information from gaming activities held under your Annual Bingo License. Enter on this schedule
information from your organization's accounting period and not the licensing period. The accounting period is a 12-month
period; the year-end will always occur one month prior to the end of the gaming period. For example, if your bingo license
expires 5/31/97, then your accounting period will be from 5/1/96 through 4/30/97.
C
Enter your accounting period: From * _________________________ To _________________________ (*Enter this as the 1st month below.
C
Enter your Annual Bingo License # ____________________________________.
See instructions on page 3.)
A
B
C
Write in
Gross Charity
Prize
Gaming
Name of
Gaming Revenue
Payouts
Revenue
-
=
Month
(eg. 1st = 1st month of accounting period)
=
-
1st
$
$
$
=
-
2nd
=
-
3rd
-
=
4th
=
-
5th
=
-
6th
=
-
7th
=
-
8th
-
=
9th
=
-
10th
=
-
11th
=
-
12th
1. Total charity gaming revenue (less prize payouts) from annual bingo license:
$
1C
add amounts in Column C and enter total here .....................................................
Schedule 2:
Enter information from gaming activities held under your single event licenses during the same
12-month time period listed on Schedule 1 above. Attach additional sheets if needed.
Single Event
A
B
C
License
Gross Charity
Prize
Gaming
-
Number
Gaming Revenue
Payouts
=
Revenue
#
-
=
$
$
$
#
-
=
#
-
=
#
-
=
#
-
=
#
-
=
#
-
=
#
-
=
#
-
=
#
-
=
#
-
=
2.
Total charity gaming revenue (less prize payouts) from single event licenses:
$
2C
add amounts in Column C and enter total here .....................................................
Schedule 3:
Totals
$
3C
3.
Enter the amount from Schedule 1, line 1C ..........................................................
$
4.
Enter the amount from Schedule 2, line 2C ..........................................................
4C
5.
Total gross charity gaming revenue (less prize payout): add lines 3C and 4C.
$
Enter total here and on page 1, line 1....................................................................
5C
2
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Parent category: Financial