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<br />MINNESOTA - REVENUE <br />Gambling Receipts and Expenses by Site <br /> <br />License and Sile permit number <br /> <br />Premises name <br /> <br />B-03074 029 <br /> <br />. "The Blue..F:ox ~__..____. <br /> <br /> A <br /> Gross receipts <br />1A 1B <br />2A 2B <br />3A 3B <br />4A ,00 4B <br /> <br />1 Bingo. <br /> <br />2 Raffles. <br /> <br />3 Paddletickets <br /> <br />4 Add lines 1 through 3 <br /> <br />5 If line 6e of last month's Form G1 is negative, <br />see instructions. pg. 9 <br /> <br />.00 <br /> <br />5A <br />6A <br /> <br />.00 6B <br /> <br />6 Subtract line 5 from line 4 _ <br /> <br />7 Income from interest and dividends <br />(see instruct;ons, pg. 9) . <br /> <br />7A <br />8A <br /> <br />8B <br /> <br />8 Tipboards. <br /> <br />9 Pulltabs . <br /> <br />9A <br /> <br />123,996,00 9B <br /> <br />10 Add lines 61hrough 9. Line 10C is <br />your gross profit for the month <br /> <br />10A <br /> <br />123,996.00 10B <br /> <br />There are no lines 11-17. <br /> <br />. <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 fisted on distributor's invoices) <br />20 Add lines 18 and 19 <br /> <br />21 Ending inventory (dollar yalue on the las! 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 lGl01O, Schedule C/D since beginning gambling activities <br />25 Advertising expenses (see instructions, 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 laVlfful 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 conducling 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 investigation 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 exces.s cash short (this is a negative amount; see instructions, pg. 8) <br /> <br />. <br /> <br />35 Reimbursement for negative expense calculation (this is a negative amount; see inst, pg. 9) <br /> <br />36 Total allowable expenses. (add lines 22 through 35) <br /> <br />(Rev 11102} <br /> <br />B <br />Prizes <br /> <br />.00 4C <br /> <br />5C <br />.006C <br /> <br />7C <br />8C <br /> <br />97,696,00 9C <br /> <br />97,696,00 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 />Month/year <br /> <br />11/2005 <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 />26,300.00 <br /> <br />26,300,00 <br /> <br />1,089.75 <br />1,819.99 <br />2.909.74 <br /> <br />1,037.03 <br />1.872.71 <br /> <br />5,486.68 <br /> <br />166.11 <br />284.94 <br /> <br />1,750.00 <br /> <br />(205.02) <br /> <br />238.00 <br /> <br />9,593.42 <br />