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<br />M~SOTA-REVENUE Schedule A <br />Gambling Receipts and Expenses by Site <br />PH~mrses name Ucense and Site permit number Month/year . <br />The Blue Fox 8-03074 029 OS/2005 <br /> A B C <br /> Gross receipts Prizes Net receipts <br /> Bingo. 1A 18 1C 0.00 <br />2 Raffles. 2A 2B 2C .00 <br />3 Paddletickets 3A 3B 3C 0.00 <br />4 Add lines 1 through 3 4A .00 4B .00 4C .00 <br />5 If line Be of last month's Form Gl is negative, <br /> see instructions, pg. 9 5A ,00 5C .00 <br />6 Subtract line 5 from line 4 . 6A .00 6B .00 6C 00 <br />7 Income from interest and dividends <br /> (see instructions, pg. 9) 7A 7C <br />8 Tipboards. 8A 8B 8C .00 <br />9 Pulltabs. 9A 127,955.00 9B 100,385.00 9C 27,570,00 <br />10 Add lines 6 through 9. line 1 DC is 27,570,00 <br /> your gross profit for the month 10A 127,955,00 10B 100,385.00 10C <br /> <br />There are no lines 11-17. <br /> <br />18 Beginning inventory (from line 21 of Jast 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 percenllax listed on distnbutor's invoices) <br />20 Add Hnes 18 and 19 <br /> <br />21 Ending inventory (dollar value on the fast day of the month - - do not include sales tax, <br />freight charges or the 1. 7 percent tax on distributor's 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 />Fonn G1 or Form LG1010, Schedule C/O since beginning gambling activities <br />25 Advertising expenses (see instructions. pg.9) <br /> <br />26 Accounting services for lawful gambling lax 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 and/or repair expenses for office furnishings, office equipment <br />and deVices used for gambling <br />29 Rent for conducting lawful gambling <br /> <br />30 UWities and other related expenses <br /> <br />31 Theft insurance and the amount permitted for liability insurance <br /> <br />32 Local government investigalion fee, and costs for new or renewed gambling <br />manager's bond <br />33 Cash long or cash short (if cash long, put parentheses around 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 negarive amount; see insf., P9- <br /> <br />36 Total allowable expenses (add Jines 22 through 35) <br /> <br />(Rev_ 11/02) <br /> <br />18 <br />19 <br />20 <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 />35 <br />91 <br />36 <br /> <br />. <br /> <br />39520 <br />2,095.09 <br />2,49029 <br /> <br />398.77 <br />2,091.52 <br />5,630.82 <br /> <br />193,69 <br />46148 <br /> <br />1,750,00 <br /> <br />40.00 <br /> <br />15900 <br /> <br />. <br /> <br />10,32651 <br />