Form Wv/bgo-3 - Super, Annual, Limited And State Fair Bingo Financial Report Page 2
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4WV/BGO-3
SUPER, ANNUAL, LIMITED & STATE FAIR BINGO FINANCIAL REPORT
rtL176 v 10-web
PLEASE USE BLUE OR BLACK INK ON ALL FORMS
NAME OF BANK AND BINGO CHECKING ACCOUNT NUMBER
NAME OF BANK
BINGO CHECKING ACCOUNT NUMBER
SCHEDULE A - RECEIPTS FOR REPORTING PERIOD
1.
Admission or Receipts
.
2.
Sales of Supplies
.
3.
Donated Prizes (Fair Market Value)
.
4.
Other Receipts (Attach Itemized Sheet)
.
5.
Total Receipts (Add Lines 1 through 4) Enter here and on Page 1 Line 1
.
SCHEDULE B - PRIZES
1.
Cash or Check
.
2.
Merchandise — Cash Value at Time of Purchase
.
3.
Donated Prizes (Value)
.
4.
Other Prizes (Door Prizes, Winner Take All, Penny Games)
.
5.
Total All Prizes (Add Lines 1 through 4) Enter here and on Page 1 Line 2
.
SCHEDULE C - EXPENSES
1. Rental
.
2. Advertising
.
3. Custodial Service
.
4. Equipment & Supplies
.
5. Security Personnel
.
6. Salaries for Bingo Operators (Attach List)
.
7. Other (Explain)
.
8. Total Bingo Expenses (Add Lines 1 through 7) Enter here and on Page 1 Line 3
.
THE FINANCIAL RETURN MUST BE CERTIFIED BY A CERTIFIED PUBLIC ACCOUNTANT OR BY A LICENSED
PUBLIC ACCOUNTANT IF SCHEDULE A LINE 5 (TOTAL RECEIPTS) EXCEEDS $50,000.
AGREEMENT
I,
, AS AN AUTHORIZED REPRESENTATIVE OF
CERTIFY OR AFFIRM THAT THE STATEMENTS AND ITEMS ENTERED HEREIN AND ATTACHED HERETO ARE TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE
(Name - Type or Print)
(Signature)
(Date)
(Telephone Number)
(Email Address)
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