Cg-8 - Annual License Financial Report Template

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For Official Use Only
CG-8, ANNUAL LICENSE FINANCIAL REPORT
Date Received
State Form 45387 (R4 / 6-11)
Reviewed By
Approved by State Board of Accounts, 2011
Date Reviewed
INDIANA GAMING COMMISSION
Date Keyed
INSTRUCTIONS: This report must be filed with the annual CG-21 and the annual renewal application.
Organization name (please type or print as it appears on your qualification application)
Address of principal office (number and street; do not enter a P.O. Box Number)
State
ZIP code
County
City
Organization telephone number Please include extension number
Organization Fax Number
(
)
(
)
Federal identification number (FID)
Email address
Contact’s telephone number
Please include extension number
Contact name and title
(
)
Average attendance of each event:
Number of events held during this accounting period:
Current License number
License type
Enter financial accounting period for this license: From ____________________ To ____________________
ANNUAL PPT LICENSE ONLY - ANSWER THE FOLLOWING QUESTIONS.
Did your organization conduct “Winner take all drawings (qualified drawings)” during this license period?
Yes
No
Total number of daily ________ weekly ________ monthly ________ drawings held during this licensing period.
If yes, what was the total prize payout for this period?
$__________________________
SIGNATURE
I certify under penalty of perjury, that I have examined this report and to the best of my knowledge and belief, it is complete and correct.
Signature of Presiding Officer
Printed name
Title
Daytime telephone number
Date (month, day, year)
Printed name
Daytime telephone number
Signature of Secretary
Date (month, day, year)
ENDING INVENTORY STATEMENT
Attach Schedule CG-INV showing ending inventory of your pull tabs, punchboards, and tip boards as of the last day of your accounting period.
Mail the completed report to:
Indiana Gaming Commission
Charity Gaming Division
101 W. Washington St., East Tower, Suite 1600
Indianapolis, Indiana 46204
Telephone: (317) 232-4646
Fax: (317) 232-0117
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CG-8

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