Form 35a - Nebraska Lottery By Pickle Card Annual Report - 2012-2013 Page 6
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9NEBRASKA SCHEDULE I — Lawful Purpose Disbursements
FORM 35A
and Bank Account Information
Schedule I
Attach this page to Form 35A (page 1).
Page 2
Organization's Name on Form 35A
Nebraska ID Number
35 —
Part A — Lawful Purpose Disbursements (Do not include pickle card expenses reported on page 1.)
Attach additional sheets, if necessary.
$
1 Disbursements from pickle card checking account for operating expenses of the organization ........... 1
2 Transfers from pickle card checking account to general fund for operating expenses of the organization . 2
3 Transfers from pickle card checking account to special fund or trust (do not include savings or
C.D.’s listed below). Indicate name of fund and its intended use
3
4 Outside donations (attach itemized list or use reverse side to list the name and address of
recipient, check number, date, amount, and description of intended use) ............................................ 4
$
5 Total lawful purpose disbursements (total of lines 1 through 4) ............................................................ 5
Part B — Bank Account Information
• Enter information from check register or bank statement for each account maintained for revenues from pickle cards.
• Attach additional sheets, if necessary.
SAVINGS OR C.D.’s
CHECKING
(List each account separately)
Name of financial institution ........................................
Address .......................................................................
City, state, zip code .....................................................
Include account activity for the period covered by this report.
$
$
$
6 Beginning balance on July 1, 2012 ....................... 6
7 Deposits ................................................................. 7
8 Interest earned ....................................................... 8
$
$
$
9 Subtotal (total of lines 6 through 8) ........................ 9
10 Disbursements (checks paid and withdrawals made) 10
11 Ending balance on June 30, 2013 or other
$
$
$
ending date:
(line 9 minus line 10) 11
$
12 Pickle card cash and checks on-hand July 1, 2012 (do not include balance on line 6) ................... 12
$
13 Pickle card cash and checks on-hand June 30, 2013 (do not include balance on line 11) ............. 13
14 Amount of deposits that were not pickle card sales (dispensing device rentals and sales $__________;
$
redeposited bad checks $__________; transfers from other accounts $___________)
(see instructions and attach itemized list, if necessary). ............................................................ 14
$
15 Amount of pickle card prizes that were paid by check ..................................................................... 15
16 Amount of disbursements that were not prizes, expenses, or lawful purpose disbursements
$
(attach an itemized list) .................................................................................................................... 16
Instructions
Part A — Lawful Purpose Disbursements
Complete Part A to report lawful purpose disbursements. Lawful purpose disbursements are uses of pickle card profits which
are not expenses of conducting a lottery by the sale of pickle cards. Transfers to special funds or trusts for building construction
or renovation, purchases of equipment, or similar dedicated uses are lawful purpose disbursements and must be reported on
line 3. Certificates of deposit purchased or transfers from the pickle card checking account to a savings account or to the bingo
checking account are not lawful purpose disbursements and must be reported in Part B, Bank Account Information.
Internal uses of pickle card profits which qualify as lawful purpose disbursements include those made for any charitable,
benevolent, humane, religious, philanthropic, youth sports, educational, civic, or fraternal activity conducted by the organization
for the benefit of its members. Purely social or recreational uses of pickle card profits are not permissible.
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