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<br />. ,MINNESOTA - REVENUE <br />Gambling Receipts and Expenses by Site <br /> <br />Premises name <br /> <br />License and Site permit number <br /> <br />The Blue Fox <br /> <br />B-03074 029 <br /> <br />A <br />Gross receipts <br /> <br />Bingo _ <br /> <br />1B <br /> <br />1A <br /> <br />2A <br />3A <br /> <br />2B <br /> <br />3B <br />.00 4B <br /> <br />2 Raffles. <br /> <br />3 Paddletickets <br /> <br />4 Add lines 1 through 3 <br /> <br />4A <br /> <br />5 If line Be of last month's Form G1 is negative, <br />see instructions, pg. 9 <br /> <br />5A <br />6A <br /> <br />.00 <br />.00 6B <br /> <br />6 Subtract tine 5 from line 4 . <br /> <br />7 Income from interesl and dividends <br />(see instructions, pg. 9) . <br /> <br />7A <br />8A <br /> <br />8B <br /> <br />8 Tipboards . <br /> <br />9 Pulltabs _ . <br /> <br />9A <br /> <br />126,69300 9B <br /> <br />10 Add tines 6 through 9. Line 10C is <br />your gross profit for the month <br /> <br />10A <br /> <br />126,693.00 10B <br /> <br />There are no lines 11-17, <br /> <br />18 Beginning inventory (from line 21 of last month's Schedule A) <br /> <br />19 Cost of gambling product obtained during the month (include sales tax and <br />freight charges, but do not include the 1.7 percent tax listed on disMbulor's invoices) <br />20 Add lines 18 and 19 <br /> <br />21 Ending inventory (dollar value on the last day of the month - - do not include sales tax, <br />freight charges or the 1.7 percent tax on distributors invoices) <br />22 Total value of gambling products sold (subtract line 21 from line 20) <br /> <br />23 Compensation and payroll taxes <br /> <br />24 Penalty and interest paid on taxes (including payroll taxes) on any <br />Form Gl or Form LG10iO, Schedule C/D since beginning gambling activities <br />25 Advertising expenses (see instructions, P9.9) <br /> <br />26 Accounting services for lawful gambling tax forms, annual financial audit or review <br />qualifying legal work <br />27 Bank service charges, office supplies; cost for authorized lawful gambling classes. <br />storage expenses and miscellaneous expenses <br />28 Purchase andlor repair expenses for office furnishings, office equipment <br />and devices used for gambling <br />29 Rent for conducting lawful gambling <br /> <br />30 Utilities and other related expenses <br /> <br />31 Theft insuranr--e and the amount permitted (or liability insurance <br /> <br />32 Local government invesligation fee, and costs for new or renewed gambling <br />manager's bond <br />33 Cash long or cash short (if cash long, put parentheses araund the amount) <br /> <br />34 Reimbursement for excess cash short (this is a negative amount; see instructions, pg. 8) <br /> <br />35 Reimbursement for negative expense calculation (this is a negative amount; see insL, pg. 9) <br /> <br />36 Total allowable expenses (add lines 22 through 35) <br /> <br />(Rev. 11/02) <br /> <br />B <br />Prizes <br /> <br />.00 4C <br /> <br />5C <br />.006C <br /> <br />7C <br />8C <br /> <br />101,593.00 9C <br /> <br />101,593.00 10C <br /> <br />18 <br /> <br />19 <br />20 <br /> <br />21 <br />22 <br />23 <br />24 <br />25 <br />26 <br />27 <br />28 <br />29 <br />30 <br />31 <br />32 <br />33 <br />34 <br /> <br />35 <br /> <br />36 <br /> <br />Schedule A <br /> <br />IIAonth/year <br /> <br />01/2005 <br /> <br />. <br /> <br />C <br />Net receipts <br /> <br />1C <br /> <br />2C <br />3C <br /> <br />0,00 <br /> <br />.00 <br />0.00 <br /> <br />00 <br /> <br />,00 <br /> <br />.00 <br /> <br />.00 <br /> <br />25,10000 <br /> <br />25,10000 <br /> <br />436.46 <br />1,978.21 <br />2,414.67 <br /> <br />. <br /> <br />307.09 <br />2,10758 <br />5,142.49 <br /> <br />214.50 <br />281.95 <br /> <br />1,750.00 <br /> <br />50.00 <br /> <br />(33,00) <br /> <br />9,51352 <br /> <br />. <br />