Form Ador 71-1001f - Financial Report For Bingo License
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8Arizona Department of Revenue • Bingo Section
Phoenix: (602) 716-7801
FINANCIAL REPORT FOR BINGO LICENSE
CLASS “B” OR CLASS “C”
REPORTING PERIOD: From
through
.
Amended Report
LICENSEE’S NAME AND ADDRESS
LICENSE NO.
LICENSE CLASSIFICATION
Class B
Class C
NO. OCCASIONS
NO. PATRONS
PHONE NUMBER WITH AREA CODE
Please read
instructions
beginning on page 7.
GROSS RECEIPTS
(ARS 5-401.9)
1 Admissions charges and card sales (ARS 5-406.R) ...............................................................................
1
$
2 Special bonus game sales (ARS 5-406.Q)..............................................................................................
2
$
3 Sale of bingo supplies .............................................................................................................................
3
$
4 Interest: Checking/savings accounts (ARS 5-407.D) .............................................................................
4
$
5 Cash over ................................................................................................................................................
5
$
6 NSF Checks: Caution! Lines 6A thru 6D have changed. Please read carefully.
6A
Received prior quarter/month and collected this quarter ................................
6A $
6B
Income from charges for NSF checks.............................................................
6B $
6C
Received this quarter/month; not collected .....................................................
6C $
6D
Adjusted NSF Income: Add lines 6A and 6B, then subtract line 6C. Enter the amount ................
6D $
7 Gross Receipts: Add lines 1, 2, 3, 4, 5 and 6D ....................................................
7
$
8 Prizes (from page 2, line 18) .................................................................................
8
$
9 Adjusted Gross Receipts: Subtract line 8 from line 7 .............................................................................
9
$
10 Schedule I (from page 4, line 33) ............................................................................................................
10
$
11 Net Proceeds: Subtract line 10 from line 9 .............................................................................................
11
$
12 Ratio of Net Proceeds (ARS 5-407.B): Divide line 11 by line 9 ..............................................................
12
%
13 Bingo Tax (ARS 5-414): Check one box.
Class B: 1.5% of line 7 (multiply the amount on line 7 by .015) – or –
Class C: 2.0% of line 7 (multiply the amount on line 7 by .020) .....................
13
$
14 Penalty/Interest (from page 2, line 21) ..................................................................
14
$
15 TOTAL SUBMITTED (Add lines 13 and 14) ............................................................................................
15
$
Continued on page 2
ADOR 71-1001f (4/06)
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