Form Wv/raf-3 - Annual Raffle Financial Report Form
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1
2WV/RAF-3
REPORTS DUE 30 DAYS
Rev. 6/00
AFTER EXPIRATION OF LICENSE
STATE TAX DEPARTMENT
CHARITABLE BINGO/RAFFLE UNIT
P. O. BOX 1143
CHARLESTON WV 25324-1143
ANNUAL RAFFLE FINANCIAL REPORT
WEST VIRGINIA IDENTIFICATION NUMBER, NAME, ADDRESS, PHONE NUMBER
REPORT PERIOD
TO
DATE DUE:
GROSS PROCEEDS:
1
SALE OF RAFFLE TICKETS
$
2
DONATED PRIZES (Value)
$
3
CHILD CARE SERVICES
$
4
OTHER PROCEEDS
$
5
TOTAL PROCEEDS (ADD LINES 1 THRU 4)
$
$
LINE 5 TOTAL GROSS PROCEEDS
5
PRIZE PAYOUTS:
6
CASH OR CHECK
$
7
MERCHANDISE (Value)
$
8
DONATED PRIZES (Value)
$
9
DOOR PRIZES
$
10
TOTAL ALL PRIZES (ADD LINES 6 THRU 10)
$
*
LINE 10 TOTAL PRIZE PAYOUTS
10
Complete Raffle Schedule 1 listing winners of more than $100.00 at any occasion
$
LINE 11 RAFFLE REVENUE LINE 5 MINUS 10
11
$
RAFFLE EXPENSES:
12
RENTAL
$
13
SALARIES & RELATED PAYROLL TAXES
$
14
BAD CHECKS
$
15
UTILITIES
$
16
RAFFLE GAMES
$
17
CUSTODIAL, SECURITY PERSONNEL AND CHILD CARE
$
18
MAINTENANCE AND REPAIRS
$
19
OTHER (License Fee & etc.)
$
20
TOTAL EXPENSES (LINES 12 THRU 19)
$
LINE 20 TOTAL RAFFLE EXPENSES (Can Not Exceed 25% of Gross Proceeds.)
20
$
21
NET PROCEEDS (LOSS) (SUBTRACT LINE 20 FROM LINE 11)
NET PROCEEDS
21
$
NAME OF BANK AND RAFFLE CHECKING ACCOUNT NUMBER: _________________________________ ____________________
NAME
ACCOUNT #
22.
BEGINNING BALANCE (UNEXPENDED BALANCE AT END OF LAST REPORT PERIOD)
22
$
23.
NET PROCEEDS (LOSS) FOR THIS PERIOD (LINE 21)
$
23
24.
OTHER DEPOSITS OR ADJUSTMENTS IN SPECIAL RAFFLE ACCOUNT:
(Interest earned, etc.) (Must be explained in detail
24
$
25.
NAMES OF ORGANIZATIONS AND AMOUNTS CONTRIBUTED THIS PERIOD:
(If necessary, attach additional sheet)
25
$
26.
____________________________________________________________________________
26
$
Ending Unexpended Balance (22 +/- 23 +/- 24 – 25 = 26) (Must match checkbook)
27.
Year-End Inventory (Dollar Amount Paid for Games on Hand)
27
$
PERCENTAGE USED TO PRO-RATE EXPENSES (IF APPLICABLE)
CONCESSIONS:
Concession Operator:
Proceeds
$_______________________
Expenses
$_______________________
NET PROFIT (LOSS)
$
REVERSE SIDE: COMPLETE DETAILED CHECK LISTING AND SIGN RETURN WHERE INDICATED.
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