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<br />MINNESOTA * REVENUE <br />Gambling Receipts and Expenses by Site <br /> <br />o Check here if you had no gambling activity during the month at this site. <br />location Name License Number <br /> KELL V'S KORNER 00584 <br /> Column A <br /> gross receipts <br /> 1 Bingo 1 0.00 <br /> 2 Raffles 2 0.00 <br /> 3 Paddletickets 3 16180.00 <br /> 4 Add lines 1 through 3 4 16180.00 <br />- 5 If line 6C of last month's Form G1 is negative, <br />ii: see instructions, pg. 9 5 0.00 <br />0 <br />... <br />0- 6 Subtract line 5 from line 4 6 16180.00 <br />III <br />III <br />0 7 Income from interest and dividends <br />... <br />(!) (see instructions, pg. 9) 7 0.00 <br /> 8 Tipboards 8 0.00 <br /> 9 Pulltabs 9 31763.00 <br /> 10 Add lines 6 through 9. Line 10C is <br /> your gross profit for the month 10 47943.00 <br /> <br />Schedule A <br /> <br />Month and year rep~rted <br />4 I 2003 " <br /> <br />Site permit number <br />010 <br /> <br />Column B <br />prizes <br />0.00 <br /> <br />0.00 <br /> <br />13992.00 <br /> <br />13992.00 <br /> <br />Column C <br />net receipts <br />0.00 <br /> <br />0.00 <br /> <br />2188.00 <br /> <br />2188.00 <br /> <br />13992.00 <br /> <br />0.00 <br />2188.00 <br /> <br />0.00 <br />25481.00 <br /> <br />0.00 <br />0.00 <br />. <br />6282.00 <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 products obtained during the month (include sales tax and <br />~ freight charges, but don't include the 1.7 percent tax listed on distributors' invoices) <br />.s <br />5i 20 Add lines 18 and 19 <br />> <br />.E 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 /> <br />22 Total value of gambling products sold (subtract line 21 from line 20) <br /> <br />23 Compensation and payroll taxes <br /> <br />Penalty and interest paid on taxes (including payroll taxes) on any <br />Form G1 or lG1010, Schedule C/D since beginning gambling activities <br /> <br />Advertising expenses (see instructions, pg. 9) <br /> <br /> 24 <br /> 25 <br /> 26 <br />III 27 <br />Q) <br />III <br />C <br />Q) <br />c. 28 <br />>< <br />w <br />Q) <br />:0 29 <br />I'll <br />~ 30 <br />.2 <br /><( 31 <br /> 32 <br /> 33 <br /> 34 <br /> 35 <br /> 36 <br />(Rev. 11/02) <br /> <br />Accounting services for lawful gambling tax forms, annual financial audit or review <br />and qualifying legal work <br /> <br />Bank service charges, office supplies, costs for authorized lawful gambling classes, <br />storage expenses and miscellaneous expenses <br /> <br />Purchase and/or repair expenses for office furnishings, office equipment <br />and devices used for lawful gambling <br /> <br />Rent for conducting lawful gambling <br /> <br />Utilities and other related expenses <br /> <br />Theft insurance and the amount permitted for liability insurance <br /> <br />Local government investigation fee, and costs for new or renewed gambling <br />manager's bond, gambling manager's license and premises permits <br />Cash long or cash short (if cash long, put parentheses around the amount) <br />Reimbursement for excess cash short (this is a negative amount; see instructions, pg. 9) <br />Reimbursement for negative expense calculation (this is a negative amount; see inst., pg. 0) <br />Total allowable expenses (add lines 22 through 35) <br /> <br />39473.00 <br /> <br />8470.00 <br /> <br />18 855.12 <br />19 891 .70 <br />20 1746.82 <br />21 954.89 <br />22 791.93 <br />23 3252.46 <br />24 0.00 <br />25 0.00 <br />26 0.00 <br />27 305.68 <br />28 0.00 <br />29 1000.00 <br />30 0.00 <br />31 0.00 <br />32 74.00 <br />33 229.00 <br />34 0.00) <br />35 0.00) <br />36 5653.07 <br /> Minnesota Gambler <br />