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<br />MINNESOTA - REVENUE Schedule A <br />Gambling Receipts and Expenses by Site <br /> - ---- -------- ----- <br />Premises n6me License and Site permit number Monthlyear <br />The Blue Fox B-03074 029 09/2005 . <br /> ~------ ----- _. <br /> A B C <br /> Gross receipts Prizes Net receipts <br /> Bingo. 1A 1B 1C 0,00 <br />2 Raffles. 2A 2B 2C .00 <br />3 Paddlelickets 3A 3B 3C 0,00 <br />4 Add lines 1 through 3 . . . . . . . . . . - . 4A 00 4B .00 4C .00 <br />5 If line 6c of last month's Form G1 is negative, <br /> see instructions, pg, 9 SA .00 SC ,00 <br />6 Subtract line 5 from line 4 . . 6A ,00 6B .006C ,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 117,220,00 9B 93,899.00 9C 23,321,00 <br />10 Add lines 6 through 9. LIne 1 DC is 23,321.00 <br /> your gross profit for the month 10A 117,220.00 10B 93,899.00 10C <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 safes tax and <br />freight charges, but do not include the 1.7 percent tax listed on distributor'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 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 />Form G1 or Form LG101O, Schedule C/D since beginning gambling activities <br />25 Advertising expenses (see ;nstructions, pg.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 !awful 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 Utilities 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 Dr 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 (tNs is a negative amount; see instructions, pg. 8) <br /> <br />35 Reimbursement for negative expense calculation (this is a negative amount; see ins!., P9- <br /> <br />36 Total allowable expenses (add lines 22 through 35) <br /> <br />(Rev. 11102) <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 />9) <br />36 <br /> <br />. <br /> <br />882.01 <br /> <br />2,023.S6 <br /> <br />2,90S,S7 <br /> <br />866.21 <br />2,039.36 <br />5,201,19 <br /> <br />8S.80 <br /> <br />305.40 <br /> <br />1,750,00 <br /> <br />62.00 <br /> <br />9,443,7S <br /> <br />. <br />