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<br />MINNESOTA Department of Revenue <br />Receipts and Expenses Per Premises <br /> <br />G-1 Schedule A <br /> <br />Organization license Number Premises pell11it number Premises Name <br />00584 8-00584-010 KELLY'S KORNER <br /> <br />Month and year reported <br />9 J 2002 <br /> <br />Lines 1-10 correspond to Form G-1. <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 6c of last month's Form G-1 or <br />Schedule A is negative, list <br />(without parentheses) in columns A and C <br /> <br />6 Subtract line 5 from line 4 <br /> <br />7 Income from interest and dividends (fill <br />in same amount in columns A and C) <br /> <br />8 Tipboards <br /> <br />9 Pulltabs <br /> <br />Column A <br />gross receipts <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />1 <br />2 <br />3 <br />4 <br /> <br />5 <br />6 <br /> <br />0.00 <br />0.00 <br /> <br />7 <br />8 <br />9 <br /> <br />0.00 <br />0.00 <br />34845.00 <br /> <br />10 Add lines 6 through 9. Line 1 Dc is your <br />gross profit for the month 10 34845.00 <br /> <br />There are no lines 11-17. <br />Lines 18-36 correspond to Form G-1. <br /> <br />18 Beginning inventory (from line 21 of last month's Form G-1) <br /> <br />19 Cost of gambling equipment obtained during the month. (Include sales <br />tax, but do not include the 1.7 percent tax listed on distributo~s invoices) <br /> <br />20 Add lines 18 and 19 <br /> <br />21 Ending inventory (dollar value on the last day of month; do not include sales <br />tax or 1.7 percent tax listed on distributo~s invoices) <br /> <br />22 Total value of the gambling equipment sold (subtract line 21 from line 20) <br /> <br />23 Compensation and payroll taxes <br /> <br />24 Penalty and interest you paid on taxes, including payroll taxes, on any <br />Form G-1 or Schedule C since beginning gambling activities <br /> <br />25 Advertising <br /> <br />26 Accounting services for lawful gambling tax forms, annual audit or review, <br />and qualifying legal work <br /> <br />27 Bank service charges; office supplies; lodging, meals and transportation for lawful <br />gambling classes conducted by state agencies; and miscellaneous expenses <br /> <br />28 Purchase and/or repair expenses for office furnishings and office equipment <br />used for gambiing, and devices used for gambling <br /> <br />29 Rent for conducting lawful gambling <br /> <br />30 Utilities used for conducting lawful gambling <br /> <br />31 Theft insurance and the amount permitted for liability insurance <br /> <br />32 Local government investigation fee and cost for new or renewed gambling <br />manager's bond, gambling managers license and premise permits <br /> <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) <br /> <br />35 Reimbursement for negative expense calculation (This is a negative amount) <br /> <br />36 TOTAL ALLOWABLE EXPENSES (add lines 22 through 35) <br /> <br />6001010 (Rev. 07/99) <br /> <br />1- <br /> <br />Column B <br />priz.es <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br />29222.00 <br /> <br />29222.00 <br /> <br />Column C <br />net receipts <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />0.00 <br />0.00 <br /> <br />0.00 <br />0.00 <br />5623.00 <br /> <br />5623.00 <br /> <br />18 931.67 <br />19 569.23 <br />20 1500.90 <br />21 922.89 <br />22 57801 <br />23 2567.64 <br />24 0.00 <br />25 75.00 <br />26 0.00 <br />27 624.90 <br />28 60.00 <br />29 1000.00 <br />30 0.00 <br />31 0.00 <br />32 000 <br />33 92.00 <br />34 0.00) <br />35 0.00) <br />36 4997.55 <br /> Minnesota Gambler <br />