Form 04-828 - Games Of Chance And Contests Of Skill - Permittee Quarterly Report - 2007
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State of Alaska, Department of Revenue
State of Alaska
Tax Division, Gaming Group
Games of Chance and Contests of Skill
PO Box 110420
Juneau, Alaska 99811-0420
2007 Permittee Quarterly Report
Phone (907) 465-2320
AS 05.15.080(a)
This form is also available on the Internet at
Federal EIN
Permit Number
Organization Name
Mailing Address
City, State, Zip
Telephone Number
Fax Number
E-mail Address
April - June
January - March
July - September
October - December
Report Period (check one):
May 15
August 14
November 14
February 14
Due Date:
Types of Activity (check all applicable):
Pull-Tab
Bingo
Raffle
Contest of Skill
Fish Derby
Dog Mushers' Contest
Other - Specify:
__________________________________
ACTIVITIES CONDUCTED BY OPERATOR OR MULTIPLE-BENEFICIARY PERMITTEE (MBP)
Enter amounts from Schedule A (Activity Report by Permittee) of the Operator or MBP Quarterly Reports.
1. Gross receipts from all games (Column I, line 1)……………………………………………………………… 1
2. Taxes reported from all games (Column I, line 2)…………………………………………………………….. 2
3. Cost of Prizes reported for all games (Column I, line 3)……………………………………………………… 3
4. Adjusted gross income from all games (Column I, line 4)……………………………………………………. 4
5. Game-related expenses from all games (Column I, line 5)…………………………………………………… 5
6. Net proceeds from all games (Column I, line 6)………………………………………………………………. 6
ACTIVITIES CONDUCTED BY PERMITTEE AND VENDOR
7. Gross receipts from all permittee and vendor activity………………………………………………………… 7
8. Taxes reported from all games …………………………………………………………………………………. 8
9. Prizes awarded from all permittee and vendor activity (including cash, merchandise, services, etc.)…… 9
10. Adjusted gross income from all permittee and vendor activity………………………………………………. 10
11. Game-related expenses from all permittee and vendor activity……………………………………………… 11
12. Net proceeds from all permittee and vendor activity………………………………………………………….. 12
13. Total net proceeds from permittee, vendor, operator and MBP activity (line 6 plus line 12)……………… 13
We declare under penalty of unsworn falsification, that we have examined this report, including accompanying schedules and statements,
and to the best of our knowledge and belief, it is true and complete.
Member in Charge or Agent Signature / Date
Printed Name
X
President or Treasurer Signature / Date
Printed Name
X
Paid Preparer's Signature / Date
Printed Name
X
Firm Name
Firm Address, City, State, Zip
DEPT USE ONLY
PMD:
Attach a Schedule D Pull-Tab Attachment, for closed games.
Attach a Calcutta pool report form for each Calcutta pool conducted in the quarter.
Form 04-828 Rev. 12/06 Page 1
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