Form 04-843 - Operator Quarterly Report - 2001 Page 4
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5Department of Revenue
Permit Number
Permittee Name
License Number Operator Name / dba
Quarter (check one)
1st
2nd
3rd
4th
SCHEDULE D: PULL-TAB ATTACHMENT
Page _____ of _____
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 04-843 (Rev 08/00) Page 4
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