Form 35k - Nebraska County/city Lottery Annual Report - 2013 Page 3
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6Nebraska County/City Lottery Annual Report
FORM
35K
for the fiscal year or short reporting period
beginning _________________, 20____ and ending _________________, 20____.
Page 1
Name of County/City/Village (Sponsor)
Nebraska ID Number
35 —
Name of Lottery Operator
Lottery Operator’s Email Address
Method of Accounting
Cash
Accrual
Other ____________________________________________
PART A — INCOME, EXPENSES/DISBURSEMENTS, PROFIT AND INTEREST
Income:
$
1 Gross proceeds ..................................................................................................................................... 1
2 Prizes paid ............................................................................................................................................ 2
3 Net proceeds (line 1 minus line 2) ......................................................................................................... 3
4 Overage or (Shortage) .......................................................................................................................... 4
5 Adjusted net proceeds .......................................................................................................................... 5
Expenses/Disbursements:
$
6 Lottery operator commissions ............................................................................................................... 6
7 State lottery taxes ................................................................................................................................. 7
8 License fees .......................................................................................................................................... 8
9 Audit and legal fees ............................................................................................................................... 9
10 Other expenses/disbursements (attach itemized list) ............................................................................ 10
11 Total expenses/disbursements (total of lines 6 through 10) .................................................................. 11
Net Profit:
$
12 Total available for distribution (line 5 minus line 11) .............................................................................. 12
13 Total interest earned (total of line 3, page 2) ......................................................................................... 13
14 Total available for community betterment (line 12 plus line 13) ............................................................. 14
PART B — MISCELLANEOUS INFORMATION
$
15 Amount owed to the sponsor at the end of the period .......................................................................... 15
$
16 Amount owed to the lottery operator at the end of the period ............................................................... 16
Under penalties of law, I declare that as a governing official of the county/city/village of ______________________________
I have examined this report, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is complete, true and accurate.
This report will be/was made available to the residents of the county/city/village of__________________________ on
______________.
Date
sign
(
)
here
Signature of Preparer
Date
Daytime Phone Number
Print Name of Preparer
Address
City/State
Zip Code
Email Address
(
)
Signature of Governing Official
Title
Daytime Phone Number
Print Name of Governing Official
Address
City/State
Zip Code
Email Address
This report and statements are due within 90 days of the end of the reporting period.
Mail to: Nebraska Department of Revenue, PO Box 94855, Lincoln, NE 68509-4855.
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