Form Cg-21 - Indiana Annual Bingo License Gross Receipts Report Page 3
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2
3Schedule 4:
Enter gross receipts received by your organization for the same accounting period used on Schedules 1 and 2, but do not include any of the charity
gaming receipts reported in Column A of Schedules 1 and 2.
Enter your accounting period: From * _________________________ To _________________________ *Enter this
as the 1st month in the first column below.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
Contributions,
Membership
Investment
Income from
Income from
Program service
Rental income
Miscellaneous
Total gross
gifts, grants,
dues and
income
sale of assets
retail sales
& other special
Income
income: add
(interest
dividends, etc.)
(other than
Month
etc.
assessments
events income
Rows (a)-(h)
inventory)
across
$
$
$
$
$
$
$
$
$
*1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
1(i)
$
1. Add all entries in Column (i). Enter total here and on line 2 on page 1 ......................................................................................................
General Instructions:
contributions, membership dues and assessments,
miscellaneous receipts such as any other income from
Enter in Columns (a)-(h) gross
investment income such as interest and dividends,
the charity gaming events not already reported on
income received by the month for your organization,
income from the sale of assets (other than inventory),
Schedules 1 or 2 (attach a separate statement listing
but do not include any charity gaming receipts reported
retail sales (such as food and beverages, less returns
the type of income and the amount.) Add the amounts
in Column A of Schedules 1 or 2. This report will include
and allowances), program service revenue and income
across for each month and total them in Column (i).
income received during the accounting period shown
from other special events, rental income and other gross
Add all Column (i) amounts and total on line (i). Carry
above, and should include gross income from:
this total to line 2 on page 1.
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