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TYPE II ANNUAL FINANCIAL REPORT FOR GAMING ENDORSEMENT State Form Approved by State Board of Accounts FOR OFFICE USE ONLY ALCOHOL AND TOBACCO COMMISSION INSTRUCTIONS Examined by / date 1. M/d/y 1 Gross income Pull Tabs 3 Gross income Tip Boards 4 Total Gross Income add lines 1 - 3 5 Expenses Pull Tabs Payouts 6 Expenses Punchboards Payouts 7 Expense Tip Boards Payouts 8 Expense Type II Supplies Pull tab punchboards and tip board purchases including tax and the cost of your type II endorsement last year 9 Total Expenses add lines 5 - 8 10 Net Income subtract total expenses from total gross income Endorsement renewal fees Enter Renewal Fee If line 10 is at least 0 but less than 25000 than the renewal fee is 100 AFFIDAVIT OF APPLICANT I certify under penalty of perjury that I have examined this report and to the best of my knowledge and belief it is complete and correct. Signature of applicant Printed name Daytime telephone number Date Mail completed report with renewal application to Alcohol and Tobacco Commission Attention Type II Gaming Renewals 302 W. Washington Room E112 Indianapolis IN 46204. Type or print legibly. 2. Financial report must be received 75 days before permit expires. 3. Do not complete shaded areas. STEP 1. GENERAL INFORMATION Name of applicant as printed on existing alcoholic beverage permit Type II Permit Number Name of Business as on a/b permit d/b/a State Tax I. D. number Business Address number and street city state ZIP code Business Telephone Area / Number A/B Permit Number Type II expiration date - Home Telephone Area / Number Mailing address number and street city state ZIP code Status Active Non-operational / Escrow Attach escrow letter County Enter financial accounting period for this license From To. m/d/y 1 Gross income Pull Tabs 3 Gross income Tip Boards 4 Total Gross Income add lines 1 - 3 5 Expenses Pull Tabs Payouts 6 Expenses Punchboards Payouts 7 Expense Tip Boards Payouts 8 Expense Type II Supplies Pull tab punchboards and tip board purchases including tax and the cost of your type II endorsement last year 9 Total Expenses add lines 5 - 8 10 Net Income subtract total expenses from total gross income Endorsement renewal fees Enter Renewal Fee If line 10 is at least 0 but less than 25000 than the renewal fee is 100 AFFIDAVIT OF APPLICANT I certify under penalty of perjury that I have examined this report and to the best of my knowledge and belief it is complete and correct. Signature of applicant Printed name Daytime telephone number Date Mail completed report with renewal application to Alcohol and Tobacco Commission Attention Type II Gaming Renewals 302 W* Washington Room E112 Indianapolis IN 46204. Type or print legibly. 2. Financial report must be received 75 days before permit expires. 3. Do not complete shaded areas. STEP 1. GENERAL INFORMATION Name of applicant as printed on existing alcoholic beverage permit Type II Permit Number Name of Business as on a/b permit d/b/a State Tax I. STEP 1. GENERAL INFORMATION Name of applicant as printed on existing alcoholic beverage permit Type II Permit Number Name of Business as on a/b permit d/b/a State Tax I. D. number Business Address number and street city state ZIP code Business Telephone Area / Number A/B Permit Number Type II expiration date - Home Telephone Area / Number Mailing address number and street city state ZIP code Status Active Non-operational / Escrow Attach escrow letter County Enter financial accounting period for this license From To. .