Form 04-839 - Games Of Chance And Contests Of Skill Pull-Tab Distributor Monthly Report
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4State of Alaska
Alaska Department of Revenue
Department Use Only
Tax Division, Gaming Group
FSN:
Games of Chance and Contests of Skill
PO Box 110420
Report and Tax Due Date: Last business day
Pull-Tab Distributor Monthly Report
Juneau, Alaska 99811-0420
of the month following the month in which the
AS 05.15.183(d) - .184
Telephone 907-465-2320
pull-tabs were sold or distributed in Alaska.
Federal EIN or SSN
Month
Year
Corporation Name
Gaming License Number
Alaska Business License Number
Business Name
Telephone Number
Mailing Address
Fax Number
City, State, Zip Code
Contact Person
TAX COMPUTATION
DEPT USE ONLY
1. Total ideal net from deals distributed (Schedule A and Schedule C)………………………………………… 1
2. Total ideal net from tax-paid returns and credits (Schedule B)………………………………………………… 2
3. Total ideal net from deals distributed to distributors and exempt sales (Schedule C)……………………… 3
4. Total taxable ideal net (line 1 less lines 2 and 3)…………………………………………………………………4
5. Tax Due (multiply line 4 by 3% (.03))…………………………………………………………………………… 5
6. Penalty for failure to file (1% penalty per 30 day period or part of 30 day period)…………………………… 6
7. Interest (12% annually)………………………………………………………………………………………………7
8. Total amount due (add lines 5, 6, and 7)*………………………………………………………………………8
TOPS / Receipt Number__________________________________
Check if you are remitting by:
Wire Transfer
To avoid wire transfer fees, use our free online EFT service, known as TOPS. Go to: https://
*
YOU MAY MAKE A WIRE TRANSFER OR ELECTRONIC FUNDS TRANSFER (EFT) USING TOPS FOR ALL TAX PAYMENTS. HOWEVER, IT THE AMOUNT DUE IS $100,000 OR MORE,
YOU MUST PAY BY WIRE TRANSFER OR EFT IN ACCORDANCE WITH 15 AAC 05.310.
I declare under penalty of unsworn falsification, that I have examined this report, including attachments, and to the best of my knowledge and belief, it is true and complete.
Signature of Owner or Agent
Printed Name
Title
Date
VALIDATION NUMBER
DEPARTMENT USE ONLY
PMD:
Form 04-839 (Rev. 12/07) Page 1
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