Form Rb-41 - Bingo Supplier Quarterly Report Page 2

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Step 2: List your sales or leases (continued)
5
$
________________________________ B - ___________
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__ __/ __ __/ __ __ __ __
Name
Month
Day
Year
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Number and street
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City, state, ZIP
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$
________________________________ B - ___________
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__ __/ __ __/ __ __ __ __
Name
Month
Day
Year
________________________________
Number and street
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City, state, ZIP
7
$
________________________________ B - ___________
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______
__ __/ __ __/ __ __ __ __
Name
Month
Day
Year
________________________________
Number and street
________________________________
City, state, ZIP
8
$
________________________________ B - ___________
____________________
______
__ __/ __ __/ __ __ __ __
Name
Month
Day
Year
________________________________
Number and street
________________________________
City, state, ZIP
9
$
________________________________ B - ___________
____________________
______
__ __/ __ __/ __ __ __ __
Name
Month
Day
Year
________________________________
Number and street
________________________________
City, state, ZIP
10
$
________________________________ B - ___________
____________________
______
__ __/ __ __/ __ __ __ __
Name
Month
Day
Year
________________________________
Number and street
________________________________
City, state, ZIP
11
$
________________________________ B - ___________
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__ __/ __ __/ __ __ __ __
Name
Month
Day
Year
________________________________
Number and street
________________________________
City, state, ZIP
Step 3: Sign below
Under penalties of perjury, I state that I have examined this report, and to the best of my knowledge, it is true, correct, and complete.
________________________________________________________________________________________________________________
Officer’s signature
Title
Date
RB-41 back (R-4/01)
Print
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