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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 />KELLY'S KORNER 00584 <br /> Column A <br /> gross receipts <br />n 1 Bingo 1 0.00 <br />2 Raffles 2 0.00 <br />3 Paddletickets 3 14560.00 <br /> 4 Add lines 1 through 3 4 14560.00 <br />.... 5 If line 6C of last month's Form G1 is negative, <br />l;:: see instructions, pg. 9 5 0.00 <br />0 <br />I- <br />0- 6 Subtract line 5 from line 4 6 14560.00 <br />III <br />III <br />0 7 Income from interest and dividends <br />l- <br />e> (see instructions, pg. 9) 7 0.00 <br /> 8 Tipboards 8 0.00 <br /> 9 Pulltabs 9 43939.00 <br /> 10 Add lines 6 through 9. Line 10C is <br /> your gross profit for the month 10 58499.00 <br /> <br /> 19 <br />~ <br />0 <br />.... 20 <br />c <br />CI) <br />> <br />.E 21 <br /> 22 <br /> 23 <br /> 24 <br /> 25 <br /> 26 <br />III 27 <br />CI) <br />III <br />C <br />CI) <br />a. 28 <br />>< <br />w <br />CI) <br />j5 29 <br />III <br />:: 30 <br />0 <br /><( 31 <br /> 32 <br /> 33 <br /> 34 <br /> 35 <br /> 36 <br />(Rev. 11/02) <br /> <br />Schedule A <br /> <br />Site permit number Month and year reported <br />010 3 I 2003 <br />Column B Column C <br />prizes net receipts <br /> 0.00 0.00 <br /> 0.00 0.00 <br />13198.00 1362.00 <br />13198.00 1362.00 <br /> <br />13198.00 <br /> <br />0.00 <br />1362.00 <br /> <br />0.00 <br />34979.00 <br /> <br />48177.00 <br /> <br />0.00 <br />0.00 <br />8960.00 <br /> <br />10322.00 <br /> <br />t,...., / <br />I ,,!~ l:~ <br /> <br />(There are no lines 11-17.) <br /> <br />18 Beginning inventory (from line 21 of last month's Schedule A) <br /> <br />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 /> <br />Add lines 18 and 19 <br /> <br />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 />Total value of gambling products sold (subtract line 21 from line 20) <br /> <br />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 />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. 9) <br />Total allowable expenses (add lines 22 through 35) <br /> <br />18 <br /> <br />1047.79 <br /> <br />19 <br />20 <br /> <br />728.29 <br />1776.08 <br /> <br />21 855.12 <br />22 920.96 <br /> <br />23 _.__~-128.11__ <br /> <br />24 _______d---2il~__ <br />25 ___ O.OL_ <br /> <br />26 0.00 <br /> <br />27 _____---.?667.]..2.._ <br /> <br />28 ________0.00 ___ <br /> <br />29 ____.___JOOOJlQ..____ <br />30 0.00 <br />31 0.00 <br /> <br />32 <br /> <br />33 _____145.00 __ <br />34 <br />35 <br />36 <br /> <br />0.00 <br />--------- ---- <br /> <br />__.--J_~L___ <br />( 0.00) ____ <br />___8161.,33_ <br /> <br />Minnesota Gambler <br />