Form Ador 71-1009 - Verification Record
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VERIFICATION RECORD
TYPE OR PRINT IN BLACK INK
A. OCCASION INFORMATION:
D. INDUCEMENTS:
DATE:
1. GIVEAWAY:
$
LICENSE NO.:
2. DISCOUNTS:
$
FAIR MARKET
NO. OF PLAYERS:
MINUS (-)
SALE PRICE
$
SUPERVISOR FOR OCCASION:
EQUALS (=)
INDUCEMENT VALUE
$
E. CASH RECORDS:
B. CARD SALES:
ITEM PRICE
NO.
TOTAL
WASTAGE
1. ADMISSION FEE
$
NO.
SOLD
INCOME
CARDS
PLUS (+)
2. CARD SALES
$
PLUS (+)
3. SUPPLY SALES
$
EQUALS (=)
4. GROSS RECEIPTS
$
MINUS (-)
5. CASH PAYOUTS
$
EQUALS (=)
6. REMAINING RECEIPTS
$
PLUS (+)
7. BEGINNING CASH
$
EQUALS (=)
8. CASH ON HAND
$
(-) OR (+)
9. CASH
CASH
OR
SHORT
OVER
$
MINUS (-)
10. BANK DEPOSIT
$
EQUALS (=)
TOTAL CARD SALES $
11. ENDING CASH
$
C. SUPPLY SALES:
F. ADJUSTED GROSS RECEIPTS:
ITEM
# SOLD
PRICE
INCOME
DAUBER
$
$
$
TOTAL INCOME (-)
TOTAL PRIZE (=)
ADJUSTED INCOME
GLUE
STICK
OTHER
SIGNATURE OF SUPERVISOR
TOTAL SUPPLY SALES
$
SIGNATURE OF WITNESS
DATE FORM COMPLETED
MISCELLANEOUS INFORMATION:
ADOR 71-1009 (1/08)
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Parent category: Financial