Form 04-843 - Operator Quarterly Report - 2001 Page 2
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1
2
3
4
5Department of Revenue
Permit Number
Permittee Name
License Number
Operator Name / dba
Quarter (check one)
1st
2nd
3rd
4th
SCHEDULE A: ACTIVITY REPORT BY PERMITTEE
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
Column I
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Description
Bingo
Pull-Tabs
Raffles
Total
1. Gross Receipts
2. Taxes
3. Cost of Prizes
(1)
4. Adj Gross Income
5. TOTAL EXPENSES
(2)
6. NET PROCEEDS
7. TOTAL NET PROCEEDS PAID TO PERMITTEE ……………………………………………………………………………………………………………………………………………………………………..
(1)
(2)
Subtract lines 2 and 3 from line 1.
Subtract line 5 from line 4.
SCHEDULE C: GAME-RELATED EXPENSES
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Expenses
Bingo
Pull-Tabs
Raffles
Total
8. Rental of Facility
9. Other Facility Costs
10. Contract / Pro. Services
11. Accounting
12. Wages
13. Payroll Taxes
14. Pull-Tab Tax Paid
Cost of Pull-tab Games
15.
and Bingo Cards (Sch C-1)
16. Advertising
17. Equipment Purchases
18. Operator Fee
19. Door Prizes
20. Other Expenses
(3)
21.
TOTAL EXPENSES
(3)
To Schedule A line 5.
Form 04-843 (Rev 08/00) Page 2
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