Form 35a - Nebraska Lottery By Pickle Card Annual Report

Form 35a - Nebraska Lottery By Pickle Card Annual Report - 2012-2013 Page 7

Line 4. Outside donations are amounts disbursed to eligible recipients outside of the organization. Eligible recipients are

defined in the

Nebraska Pickle Card Lottery Act Neb. Rev. Stat.§

9-309(2).

An itemized list of these types of donations must identify the recipient’s name and address, check number, date, amount,

and description of intended use.

Part B — Bank Account Information

Part B is to be utilized by the organization to report the activity in each bank account established by the organization for

revenues derived from the conduct of a lottery by the sale of pickle cards.

For each account, enter the name and address of the financial institution.

Certificates of deposit purchased or savings accounts set up with proceeds from a lottery by the sale of pickle cards should

be shown as separate bank accounts until withdrawn and used for a lawful purpose.

Complete all lines below the bank account information.

Lines 12 and 13. Include cash or checks received for pickle card sales at clubs, bingo, or festivals which have not been

deposited in the bank, cash on hand for paying pickle card prizes, and any pickle card operator checks which were not

deposited by June 30, including any checks in the possession of a sales agent.

Line 14. Funds transferred from another bank account, redeposits of certificates of deposit or bad checks, pickle card

dispensing device rental or sales, and credits from distributors are examples of deposits that are not pickle card sales.

Attach an itemized list of these amounts.

Line 16. Enter any disbursements from the pickle card checking account that are not prizes, expenses, or lawful purpose

disbursements (e.g., transfers to the bingo checking account or a savings account, repayment of a loan for start-up costs,

and payments to an escrow account).

OUTSIDE DONATIONS

Check

Name and Address of Recipient

Date

Amount

Description of Intended Use

Number

Total (enter on line 4, Schedule I on page 2) .......................................................

Form 35a - Nebraska Lottery By Pickle Card Annual Report - 2012-2013 Page 7