Form 858 - Alaska Pull-Tab Receipt Log printable pdf download

Form 858 - Alaska Pull-Tab Receipt Log

Alaska

858

Pull-Tab Receipt Log

Location

Permittee

Permit No.

Distributor

Distributor Lic. No.

Dates Distributed

Game Series (Form Number/Name/Price)

State ID Label-Stamp Number

First Day

Last Day

INSTRUCTIONS: Use this form to record information for each pull-tab prize of $50.00 or more. Complete a separate

entry on this form for each such prize. The winner MUST complete a Pull-Tab Prize Receipt form. Pull-Tab winners who

fail to provide a correct name will not be paid. Attach the winning pull-tabs and associated Pull-Tab Prize Receipts to this

Pull-Tab Receipt Log.

This page and the attached pull-tab receipts must be kept for a period of three years unless the permittee had gross

receipts exceeding $100,000 during the preceding year from activities conducted under this chapter or is required to

report under AS 05.15.080(a), must be kept for a period of two years. Photocopy this form as needed.

Reported by

Date

Amount Won

Printed Name of Prize Winner

858

0405-858 Rev 04/22/13

Form 858 - Alaska Pull-Tab Receipt Log