GC-7
I
GC-7
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
INSTRUCTIONS: Prepare report in triplicate. Within 7 days after each license period, send original to clerk of municipality, send one copy to
N.Y.S. Racing & Wagering Board, Bureau of Bell Jar & Charitable Gaming Compliance, 1 Watervliet Ave. Ext., Suite 2, Albany, NY 12206-1668,
and retain one copy for your files. Where applicable, one copy shall also be submitted to the Chief Fiscal Officer of the County.
FINANCIAL STATEMENT
OF GAMES OF CHANCE
OPERATIONS
(Please Print or Type)
Street Address Municipality
Address Where Games are Conducted, if Different:
Zip
County
Zip
ITJjITJjITJ
Date of License Period
Number of Players
A. RECEIPTS-
1. Admissions (if fee is charged)............................ ........................... ...................... $
2. Profit or Loss from games other than Merchandise Wheels................................ $
3. ~;~: ~~~~ ~ou~~e~~~;~~::d:::~~~~'h~d)'"'''''''''''''''''''''''''''''''''''''''''''''' $
$
4. Total Receipts (Add Items 1, 2 and 3)................................................................
B. EXPENDITURES - (Show only payments actually made)
Describe Expenditure Payee
Check No.
$
$
$
$
$
$
6. Total Expenditures......................... ....... ......................... ..... ................................. $
C. NET PROFIT OR (LOSS) $
1. Profit or (Loss) Before Additional License Fee (Item A4 less Item B6)...............
)..................... $
1. Rent
2. License Fee
3. Games of Chance Equipment
and Supplies
4.
Services
5.
Other Expenses
2. Additional License Fee (liST CHECK NUMBER
3. Net Profit or (Loss) (Item 1 less Item 2)............................................................... $
D. GAME BANK FUND Payee Check No. Amount
(Memo Entry Only)
E. DISPOSITION OF AND ACCOUNTING FOR NET PROCEEDS -
1. If this is organization's first license period, give opening balance, if any, in the $
Special Games of Chance Account.................... ...................................................
Source of opening balance $
2. Unexpended balance of net proceeds shown on last report..................................
L BJ-GC-7 (Rev. 4/03) Page 1 of 2
County
--,
Hours of License Period
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11111111111111111111111111111 --.J
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Net profit or (Loss) from this license period (Part C. Item 3).............................. $
Interest earned on net proceeds on deposit in interest bearing account(s)............ $
Other deposits into or adjustments in Special Games of Chance Account............ $
Explanation
--,
.LD
.LD
.LD
3.
4.
5.
.LD
$
Total net proceeds (add Items 1 through 5)..............................................,...........
Disbursements of net proceeds since last report: (Attach additional sheets if necessary)
Date Check No. Descriotion of Disbursements Name & Address ofPavee
6.
Amount
7. Total Disbursements.................... ...... ......... ...... ...................... .....
........................ $ .LD
......................... $ .OJ
8. Unexpended balance of net proceeds (Item 6 less Item 7)...........
(Include interest bearing accounts)
F. Reconciliation of Unexpended Balance (To be Completed Monthly - - Upon receipt of Monthly Bank Statement)
Depository Name of Bank Account No. Reconciled Balance
1 ) Checking
2) Savings
3) Other
Total (Must be the same as Line E8 - Unexpended Balance)............................... $
.LD
Instructions: This section must be fully completed by all parties.
I swear, or affirm that the information and statements contained herein have been examined by me and to the best of my
knowledge and belief are true, correct and complete.
Zip
County
LD/LD/ITJ
Date
Street Address City
( [IT] ) IT]] - ITID
Phone Number
Member in Charge:
Signature
Zip
County
LD/LD/ITJ
Date
Street Address City
( [IT] ) IT]] - ITID
Phone Number
Preparer (if different):
Street Address City
( [IT] ) ITIJ - ITIIJ
Phone Number
I
BJ-GC.7 (Rev. 4/03)
Signature
Zip
County
ITJ/ ITJ/ITJ
Date
11111111111111111111111111111 .J
Signature
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