Form Inv - Annual Certified Physical Inventory And Cash Count By Site
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Annual Certified Physical Inventory and Cash Count by Site
Use this form to record the site inventory of games in play and unplayed games, as well as the cash count for all forms of gambling .
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 (mm/dd/yyyy)
Part 1
(Must be completed by two individuals not involved with the gambling operation or by a CPA)
Manufacturer ID
Part Number
Serial Number
Part 2
Total of all cash counted for all forms of gambling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part 3
Was paper bingo conducted at this site?
Yes
No
If yes, then attach a copy of Form LG903 (Physical Inventory/Bingo Paper Monthly Summary) for the organization’s fiscal year-end.
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 and Form LG903, if required, to Form CI and mail to:
Minnesota Revenue, Mail Station 3350, St. Paul, MN 55146-3350.
Phone: 651-297-1772.
(Rev . 7/17)
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Parent category: Financial