Form 35k - Nebraska County/city Lottery Annual Report - 2013 Page 5

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NEBRASKA SCHEDULE I — Bank Account Information
FORM
35K
Attach this page to Form 35K (page 1).
Page 2
Name of County/City/Village (Sponsor) on Form 35K
Nebraska ID Number
35 —
• Enter information from bank statements for each account maintained for revenues and disbursements from county/city lottery (keno).
• Attach additional sheet(s) if necessary.
KENO OPERATIONS
PRIZE RESERVE
PROGRESSIVE
BIG WINS
COMMUNITY BETTER-
OTHER
Bank account name ........................................................
BANK ACCOUNT
BANK ACCOUNT
JACKPOT ACCOUNT
BANK ACCOUNT
MENT ACCOUNT
BANK ACCOUNT
Bank account number (last four digits) ...........................
ACCOUNT ACTIVITY FOR THE PERIOD COVERED BY THIS REPORT
1 Balance at fiscal year or short period
$
$
$
$
$
$
beginning date_______________ ................... 1
2 Deposits ............................................................ 2
3 Interest earned ................................................. 3
$
$
$
$
$
$
4 Subtotal (total of lines 1 through 3) ................... 4
5 Disbursements (checks and withdrawals) ........ 5
$
$
$
$
$
$
6 Balance at fiscal year or short period ending
date _______________ (line 4 minus line 5) ... 6
$
7 Amount of lottery (keno) cash on hand or outstanding deposits as of the start of fiscal year or the short period starting _______________ (see instructions). ......
7
8 Amount of lottery (keno) cash on hand or outstanding deposits as of the end of fiscal year or the short period ending _______________ (see instructions) .........
8
9 Prizes paid by check and withdrawals for keno cash (i.e. fills) during the reporting period .................................................................................................................
9
10 Deposits into the keno operations account other than daily keno receipts (i.e. transfers from prize reserve, operator, community betterment or any other
accounts, etc.) Attach itemized schedule ............................................................................................................................................................................................ 10
11 Other disbursements from the keno operations account (Attach itemized schedule) .......................................................................................................................... 11
$
12 Total community betterment expenditures paid from the community betterment bank/fund ............................................................................................................... 12
Use the space below to highlight these expenditures:
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