Form 35b - Nebraska Lottery/raf E Annual Report - 2012-2013 Page 3
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7Nebraska Lottery/Raffle Annual Report
FORM
35B
For the reporting period July 1, 2012 through June 30, 2013 or the short period
beginning ____________________, 20______ and ending ____________________, 20______.
Page 1
Organization's Name
Street or Other Mailing Address
City or Town
State
Zip Code
Nebraska ID Number
Federal ID Number
35 —
LOTTERY/RAFFLE INCOME AND EXPENSES (Do not include lawful purpose disbursements reported on Schedule I.)
Read instructions on reverse side.
$
1 Adjusted gross proceeds (Schedule II on page 3, column A, line 3) . . . . . . . . . . . . . . . . . . . . . . . . .
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2 Adjusted prizes: a Cash (Schedule II on page 3, column B, line 6) . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Check (Schedule II on page 3, column B, line 6) . . . . . . . . . . . . . . . . . . . . . . . 2b
c Merchandise (Schedule II on page 3, column B, line 6) . . . . . . . . . . . . . . . . . . 2c
$
3 Amount of prizes in line 2 which were not claimed . . . . . . . . . . . . . . . . . . . . 3
4 Gross compensation of individuals and businesses selling lottery/raffle tickets . . . . . . . . . . . . . . . . .
4
5 Compensation for services related to lottery/raffle activities (see instructions) . . . . . . . . . . . . . . . . .
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6 Cost of lottery/raffle tickets, including printing costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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7 Lottery/raffle license and permit fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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8 Lottery/raffle taxes (include any local taxes, if applicable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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9 Advertising and promotion costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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10 Cost of food, refreshments, and entertainment provided at drawing (see instructions) . . . . . . . . . . . 10
11 Interest expense and bank charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Other lottery/raffle expenses (attach an itemized list of expenses and amounts) . Do not include
lawful purpose disbursements reported on Schedule I, page 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
$
13 Total lottery/raffle expenses (total of lines 2a through 12 — do not include line 3) . . . . . . . . . . . . . . . 13
$
14 Net lottery/raffle profit (line 1 minus line 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Under penalties of law, I declare that as an officer or utilization of funds member, I have examined this report, including accompanying
schedules and statements, and to the best of my knowledge and belief, it is complete, true and accurate.
This report will be/was made available to the organization's membership on ______________________________.
Date
sign
here
Signature of Officer
Date
(
)
Print Name of Officer
Title
Daytime Phone Number
(
)
Signature of Preparer
Date
Daytime Phone Number
Print Name of Preparer
Address
City/State
Zip Code
(
)
Signature of Utilization of Funds Member
Daytime Phone Number
Email Address of Utilization of Funds Member or Preparer, if different
This report, related schedules, and statements are due by August 15, 2013.
Mail to: Nebraska Department of Revenue, PO Box 94855, Lincoln, NE 68509-4855.
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