Form Inv - Annual Certified Physical Inventory By Site
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Annual Certified Physical Inventory by Site
Use this form to record the site inventory of games in play and unplayed games . Use a separate form for each site .
Federal ID number
Minnesota tax ID number
License number
Organization name
Site name and permit number
Date taken
Fiscal year end
Type of games (check all that apply):
Pull-tabs
Tipboards
Paddletickets
Bingo
Raffles
Electronic Pull-tabs
Electronic Linked Bingo
Part 1
Part 2
(Must be completed by two individuals not involved with the gambling operation or by a CPA)
(May be completed by a member
involved with gambling operation)
Dollar Value on the
Last Day of the Month
(Do not include sales tax,
Manufacturer ID
Part Number
Serial Number
1.7% tax, or freight.)
Total from page 2 of INV
Total
Part 3
(May be completed by a member involved with gambling operation)
1 Total dollar value of physical inventory of paper and electronic linked bingo
from Form LG903 by site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Total dollar value of physical inventory of raffles from Form LG821 by site . . . . . . . . . . . . . . . . 2
3 Total dollar value of ending inventory by site (barcoded games plus bingo and raffles) . . . . . . 3
I declare that the information provided is correct and complete to the best of my knowledge and belief.
Signature of individual or CPA who completed Part I (required)
Title
Date
Signature of second individual (required if not conducted by a CPA)
Title
Date
Individuals or CPA who completed Part 1: Provide the completed and signed Form INV to the organization’s CEO or
gambling manager .
CEO or gambling manager: Attach Form INV to Forms CI and CC and mail to:
Minnesota Revenue, Mail Station 3350, St. Paul, MN 55146-3350.
Phone: 651-297-1772. TTY: Call 711 for Minnesota Relay.
(Rev. 8/13)
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