Form Ci - Annual Certified Physical Inventory And Cash Count Summary
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Annual Certified Physical Inventory and Cash Count Summary
Use this form to record the total cash count for all sites.
Organization Name
Federal ID Number
Minnesota Tax ID Number
License Number
Fiscal Year End (mm/dd/yyyy)
Site Name and Permit Number
Total Cash Count by Site
Totals
Have the following forms been attached for each site?
Form INV (Annual Certified Physical Inventory and Cash Count by Site)
Yes
Form LG903 (Physical Inventory/Bingo Paper Monthly Summary), if required.
Yes
I declare that the information provided is correct and complete to the best of my knowledge and belief.
Signature of CEO (required)
Print Name
Date
Signature of Gambling Manager (required)
Print Name
Date
Within 30 days after the end of the organization’s fiscal year, mail Form CI along with completed Form INV and Form LG903,
if required 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