GC-7Q
I
GC-7Q
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
For Quarter: 0 Jan 1 - Mar 31 0 Apr 1 - Jun 30 0 Jull - Sep 30 0 Oct 1- Dec 31 Year 20m
Instructions: Send original of this report to NYS Racing & Wagering Board, 1 W atervliet Ave. Ext., Albany,
NY 12206-1668, within 15 days after each calendar Quarter. Retain a copy for your records. Attach
completed Schedules 1 and 2; the list of all checks written this quarter; and a copy of the three most recent
monthly bank statements of the special games of chance bank accounts (including interest-bearing account(s)).
I
QUARTERLY STATEMENT OF
BELL JAR OPERATIONS
Street Address City
GC- LD - ITJJ - ITJJ - ITIITI
NYS Identification Number
Zip
County
Municipal License Number
Examined By (OFFICE USE ONLY)
A. ?ua~~~:e;:~~::: sold.............................................................................................................. ITIIJ
2. Ideal handle/total value of tickets............................... $ . LD
(from Schedule 1, column F)
Prizes (from Schedule 1, column G).................... $ 0
Unsold tickets (from Schedule 1, column H)....... $ 0
Cost of deals (from Schedule 2, line D)............... $ 0
Add lines 3, 4, and 5.................................................. 0
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.LD
3.
4.
5.
6.
7. Subtract line 6 from line 2. This is the Ideal Net Proc
B. Net Profit or (Loss) $
8. Enter 5% of line 7 "Additional License Fee" ....................
(make check payable to NYSRWB Bell Jar Collection Account
9. Subtract line 8 from line 7. This is Total Net Profit or (Loss)$
C. Statement of Net Proceeds
10. Unexpended balance of Net Proceeds from last
GC-7Q report........... ........ ....... ..... ..... ..... ......................$
11. Interest earned this Quarter from any Bell Jar
Interest-Bearing Account(s) (special checking, CDs,
and/or savings accounts)... ................... .... .......... ..... ..... $
12. Add lines 10 and 11. This is the quarterly net proceeds
and interest..... .......... ............... .......... ..... .................... .........$
13. Adju~tments. (Enter the + or - sign before the figure and $
explam: ).....
14. Combine lines 12 and 13. This is adjusted net proceeds $
and interest......... ................. ............ ............. ..... .......... ..............
15. Add lines 9 and 14. This is the Total Net Proceeds.......................$
.
.
.
$ .
eeds$ I
.LD
.0
.LD
.0
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L BJ-GC-7Q (Rev. 4/03)
Page 1 of 2
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-,
D. Unexpended Balance of Net Proceeds
16. Enter your Total Net Disbursements this Quarter (from Schedule
2, line C). DO NOT INCLUDE 5% fee and cost of deals........ $
17. Subtract line 16 from line 15. This is the Total Unexpended
Balance of Net Proceeds...... ............................. ......... ............ .............. $
E. If your organization holds bell jar monies in a special interest-bearing account (CD or savings), enter
amount held in each account(s), the respective account number, and the name of the financial institution.
Amount $ $ $
Account Number
Financial Institution
F. Fraternal and service organizations, who must donate one-third of
Total Net Profit (from line 9) to charity each year, enter amount $
donated this Quarter (from Schedule 2, line B).........................................
.m
.m
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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.
First Name
Last Name
Street Address City
( DIJ ) ITIJ - DID
Phone Number
Zip
County
rn/LIJ/rn
Date
First Name
Last Name
S(ITJ] } ITIJ - oIo
Phone Number
Zip
County
Signature
Preparer (if different):
rn/LIJ/rn
Date
First Name
Last Name
SrITTI} ITIJ rrITI
Phone Number
Zip
County
Signature
rn/LIJ/rn
Date
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SCHEDULE 2
(To be filed with GC-7Q)
--,
Name of Organization
GC- CD.. OJ].. OJ] .. ITIJIJ
NYS Identification Number
QUARTER: 0 Jan 1 _ Mar31 0 Apr 1 - Jnn 30 0 Jull - Sep 30 0 Oct 1 - Dee 31 Year 20DJ
Instructions: Send original to NYS Racing & Wagering Board, 1 Watervliet Ave. Ext., Albany NY 12206-1668,
along with the completed GC-7Q for this quarter, a completed Schedule 1, a list of all checks this quarter, and
copies of the three most recent monthly statements of the special games of chance bank account(s) (including
interest-bearing accounts). Retain copies for your records.
Schedule 2 is a worksheet which should be used to summarize checks written from the special bell jar account.
Please refer to Sections 5624.10 and 5624.21 of the Board's Rules regarding withdrawals and expenditures. All
expenditures made this quarter should be included on this Schedule. Enter the total dollar amount for each
category of checks that you wrote this quarter:
B. Total amount of checks written to "worthy causes" (donations).. B.
If you are a fraternal or service organization, enter this amount
on your GC-7Q at F
C. Add lines A and B. $ITIIIIO OJ
Total Net Disbursements this Quarter..................................... c. LL.Ll--L-l- .
Enter this amount on GC-7Q Section D, line 16 ITIIIIlJ OJ
D. Total amount of checks written for Cost of Deals........................ D. $ LL.Ll--L-l- .
Enter this amount on GC-7Q Section A, line 5
E. TO~~~~~~:i:~~~;~~..~~~t..~.~.~~~~..f~........................... E. $ DIIJ]JJ. OJ
DO NOT automatically enter this amount on your current GC-7Q. The payment of
only this quarter's 5% Additional Fee is reported on this quarter's GC-7Q, regardless of
whether the check was written this quarter or sometime (e.g., the 15 days) after this
quarter ended. A check written at the beginning of this quarter to pay last quarter's 5%
Additional Fee, would already have been reported on the last quarter's GC-7Q in
Section E, line 8, and should not be reported again.
F. Ad~~t~:;;~ ~:a~;e;~.s.~..yo.~...=~~..~~~.c~........................ F. $ DIIJ]JJ. OJ
This equals the dollar total amount of checks, on your list of all checks this quarter that
you wrote from your bell jar account(s)
$ ITIIIIO.OJ
$ ITIIIIO.OJ
A. Total amount of checks written for Operating Expenses............. A.
Note: The list of all checks should set forth the check number, date, description of the check, name and address of
the payee, and amount. As noted above, it is most helpful if the checks are grouped into the following categories:
operating expense checks, checks to "worthy causes" (donations), checks to pay for deals, and check(s) payable to
NYSRWB for the 5% Additional Fee.
BJ.GC.7Q Schedule 2 (Rev. 4/03)
III III IIII 11111 \1 II In II 11111 .J