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<br /> ---------...,------. -----..---""- <br /> license and Site permit number Month/year <br /> B-03074 029 12/2005 . <br /> ----- ------.-- ------------- <br /> A B C <br /> Gross receipts Prizes Net receipts <br />1A 1B 1C 0,00 <br />2A 2B 2C ,00 <br />3A 3B 3C 0.00 <br />4A ,00 4B ,00 4C ,00 <br /> <br />MINNESOTA - REVENUE <br />Gambling Receipts and Expenses by Site <br /> <br />Premises name <br /> <br />The Blue Fox <br /> <br />Bingo. <br /> <br />2 Raffles. <br /> <br />3 Paddle tickets <br /> <br />4 Add lines 1 through 3 .. <br /> <br />5 if iine 6c 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 instructions, pg. 9) . <br /> <br />7A <br />8A <br /> <br />8B <br /> <br />3 Tipboards. <br /> <br />9 Pul!labs. <br /> <br />9A <br /> <br />119,130,00 98 <br /> <br />10 Add fines 6 through 9. Une 10C is <br />your gross profit for the month <br /> <br />10A <br /> <br />119,130.00 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 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 gambllng 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 LG1010, Schedule C/O 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 supplles; 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 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 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 ins!., pg. <br /> <br />36 Total allowable expenses (add lines 22 through 35) <br /> <br />(Rev 11/02) <br /> <br />Schedule A <br /> <br />5C <br />.00 6C <br /> <br />.00 <br /> <br />,00 <br /> <br />7C <br />8C <br /> <br />,00 <br /> <br />94,190.00 9C <br /> <br />24.940.00 <br /> <br />94,190001OC <br /> <br />24,940.00 <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 />1.037.03 <br />2,087,38 <br />3,124.41 <br /> <br />1.04273 <br />2,081.68 <br />6,10610 <br /> <br />93.32 <br />774.66 <br /> <br />1,750,00 <br /> <br />200,00 <br /> <br />. <br /> <br />11,005.76 <br />