Form 04-833ez - Permittee Annual Financial Statement - 2003 Page 3
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32003 Permittee Annual Financial Statement - EZ
Permit Number
Permittee Name
Page _____ of _____
SCHEDULE D: PULL-TAB ATTACHMENT
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
IN
OUT
Subtotal (amounts from this page) …………………………
Use additional
sheets if necessary.
Grand Total (include amounts from all pages) …………………………
Form 04-833EZ (Rev 11/03) Page 3
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Parent category: Financial