Form 0405-810 - Calcutta Pool As 05.15.080(C) - 2013

DEPARTMENT USE ONLY

Alaska

Date Stamp

810

2013 Calcutta Pool

AS 05.15.080(c)

Due Date: Fifteen days after the Calcutta pool.

EIN

Permit Number

Organization Name

Mailing address

City, State, Zip Code

Phone Number

Fax Number

Email Address

Physical location of the Calcutta pool

Date of the Calcutta Pool

Name, type and physical location of the sporting event on which the Calcutta pool is based

Date of Sporting Event

Schedule A: Calcutta Pool Receipts

1. Gross receipts - wagers collected at auction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2. Prizes distributed to the winners of the pool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

3. Adjusted Gross Income (subtract line 2 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

4. Expenses from Schedule B, line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

5. Net proceeds (subtract line 4 from line 3; must be at least 50% of line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

Schedule B: Calcutta Pool Expenses

6. Rental of Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

7. Other Facility Costs (attach separate schedule of other facility costs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

8. Contract / Professional Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

9. Accounting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

10. Payroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

11. Payroll Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

12. Advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

13. Door Prizes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

14. Other Expenses (attach separate schedule of other expenses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14

15. TOTAL EXPENSES (add lines 6-14 and copy this amount to line 4 in Schedule A above) . . . . . . . . . . . . . . . . .

15

NOTE: All expenses of the Calcutta pool must be reported on lines 6 through 14.

16. Number of winning bids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

We declare under penalty of unsworn falsification that we have examined this report including all accompanying schedules and statements, and to the

best of our knowledge and belief it is true and complete.

Member in Charge or Agent Signature

Date

Printed Name

Date

Printed Name

President or Treasurer Signature

Date

Printed Name

Paid Preparer’s Signature

Paid Preparer’s Firm Address, City State, Zip Code

Paid Preparer’s Firm Name

Attach a copy of the facility lease, if any.

810

Mail to: Alaska Department Of Revenue, PO Box 110420, Juneau AK 99811-0420

0405-810 Rev 09/12