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Multiple-Beneficiary Permittee Member:

If your

proceeds, purpose of the disbursement, amount, date

organization participates in pull-tab gaming only

and check number) to report all payments.

If a

through an MBP, do not complete Schedule D. It

separate statement is submitted, the total from that

has been filed for your organization by the MBP.

statement must be carried forward to Schedule E and

included in the total entered on line 17, Page 1.

General Information.

Enter your organization's

name and permit number in the spaces provided.

Enter the name of your organization's operator if any

If your organization needs to hold net proceeds for a

period longer than one year, you must apply to the

pull-tab games were conducted by the operator on

your behalf during the year.

Department for special permission.

Upon good

cause shown, the Department may grant the request.

License Number. Enter the license number of the

distributor selling the game in this column.

EPOSITS

F, P

CHEDULE

AGE

State ID Stamp Label. Attach the pull-tab State ID

Use this schedule, along with Schedule F-1, Other

Stamp Labels in this column. If the label is not

Adjustments, to help reconcile the gaming account

available, write in the ID number and attach an

balance reported on Page 1.

explanation to the report.

Line 1, Total current year net proceeds. Enter the

Game Serial Number and Form Number. Enter

net proceeds computed on line 8, Page 1 of your

the serial number and form number for each game in

Annual Financial Statement.

the space provided.

Line 2, Prior year net proceeds deposited in

Gross Receipts, Prize Payout and Ideal Net. Enter

January of the current year. If your organization

the ideal gross receipts, ideal prize payout and ideal

worked with an operator last year, the December net

net in the applicable columns.

proceeds would not have been deposited until

January of this year when you received the monthly

3% Tax. Enter the 3% tax paid when the game was

report for December. This amount should be added

purchased (by your organization or by an operator

to the current year net proceeds. If your organization

purchasing pull-tab games for your organization).

conducted gaming on its own and had gross receipts

for the prior year that you did not deposit in your

Date In/Date Out. Enter the dates the game was

gaming account by December 31 of the prior year,

placed in play (date in) and completed (date out) in

the receipts not deposited by the end of the year

this column.

should also be included on this line.

ONATIONS OF

ROCEEDS

Line 3, Current year net proceeds not deposited

E, P

CHEDULE

AGE

by December 31 of current year.

If your

organization worked with an operator during

Net proceeds derived from gaming activities must be

December of the current year, the net proceeds

devoted, within one year following the year in which

received from your operator in January of this year

it was earned, to uses stated in Alaska law. List each

(for December of the prior year) should be subtracted

recipient of net proceeds, the purpose of the

from the current year net proceeds.

donation, and the amount, date and check number

for each payment.

If your organization conducted gaming on its own

and had gross receipts for the current year that were

All payments of net proceeds must be listed. The

not deposited to the gaming account by December

total from this schedule is entered on Page 1 of the

31, that amount should also be included on this line.

Annual Financial Statements, line 17. Use additional

forms as needed.

Line 4, Other deposits. Explain other deposits on

the lines provided. For example, the initial deposit

Use of net proceeds transferred to the general fund

to open the account may have been a transfer from

must also be shown in the Annual Financial

the general account.

Statement. Use Schedule E or a separate statement

including the same information (recipient of net

04-833 (Revised 11/97) Instructions

Page 9 of 10

Form 04-833 - Instructions For Annual Financial Statement - Alaska Department Of Revenue Page 10

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