Form Cc - Annual Certified Cash Count By Site

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Annual Certified Cash Count by Site

Federal ID number

Minnesota tax ID number

License number

Use this form to record the start cash amount by site. Use a separate form for each site.

Organization name

Site name and permit number

Date taken

Fiscal year end

Were there pull-tab and/or tipboard games in play at month end?

Yes (complete Parts 1, 2 and 3)

No (complete Part 1 and Part 3)

Part 1

Part 2

(Must be completed by two individuals not

(To be completed by a member involved with gambling operation if there were games in play at month end.)

involved with the gambling operation or by a CPA.)

Pull-tabs and Tipboards

Mfg

Part

Serial

Cash

Start

Cash in

Ideal gross

Value unsold

Gross receipts

Value of

Net receipts

Cash long/

number

counted

bank

hand (D – E)

receipts

tickets

(G – H)

prizes

(I – J)

short (F – K)

Totals from page 2 of CC

Totals

Start Bank Reconciliation

Part 3

(May be completed by a member involved with gambling operation)

1 Total cash counted (column D total). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Total net receipts (column K total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Subtotal (subtract line 2 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Add cash short or subtract cash long (column L total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Verified start bank for games in play (add lines 3 and 4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Start bank for other forms of gambling (i.e., paddlewheel, raffle or bingo, electronic linked bingo and electronic pull-tabs banks) and/or back-up banks . . 6

7 Total start bank by site (add lines 5 and 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

I declare that the information provided is correct and complete to the best of my knowledge and belief.

Signature of individual or CPA who completed Part I (required)

Print name

Title

Date

Signature of second individual (required if not conducted by a CPA)

Print name

Title

Date

Individuals or CPA who completed Part 1: Provide the completed and signed Form CC to the organization’s CEO or gambling manager.

CEO or gambling manager: Attach Form CC to Forms CI and INV and mail to Minnesota Revenue, Mail Station 3350, St. Paul, MN 55146-3350.

Phone: 651-297-1772. TTY: Call 711 for Minnesota Relay.