Fillable Printable Cg-8
Fillable Printable Cg-8
Cg-8
CG-8, ANNUAL LICENSE FINANCIAL REPORT
S tate Form 45387 (R4 / 6-11)
INDIANA GAMING COMMISSION
INSTRUCTIONS: This report must be filed with the annual CG-21 and the annual renewal application.
Page 1 of 3
Organization name (please type or print as it appears on your qualification application)
Address of principal office (number and street; do not enter a P.O. Box Number)
County
City
State ZIP code
Organization telephone number Please include extension number Organization Fax Number
Email address
Contact name and title
Contact’s telephone number Please include extension number
Current License number
( ) ( )
( )
License type
Federal identification number (FID)
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SIGNATURE
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.
ENDING INVENTORY STATEMENT
Attach Schedule CG-INV showing ending inventory of your pull tabs, punchboards, and tip boards as of the last day of your accounting period.
Mail the completed report to:
Indiana Gaming Commission
Charity Gaming Division
101 W. Washington St., East Tower, Suite 1600
Indianapolis, Indiana 46204
Telephone: (317) 232-4646 Fax: (317) 232-0117
Approved by S tate Board of Accounts, 201 1
Enter financial accounting period for this license: From ____________________ To ____________________
ANNUAL PPT LICENSE ONLY - ANSWER THE FOLLOWING QUESTIONS.
Did your organization conduct “Winner take all drawings (qualified drawings)” during this license period? Yes No
Total number of daily ________ weekly ________ monthly ________ drawings held during this licensing period.
If yes, what was the total prize payout for this period? $__________________________
Signature of Secretary
Daytime telephone number
Printed name
Date (month, day, year)
Signature of Presiding Officer
Printed name
Date (month, day, year)Daytime telephone number
Title
For Official Use Only
Date Received
Reviewed By
Date Reviewed
Date Keyed
Number of events held during this accounting period:
Average attendance of each event:
Reset Form
INCOME AND EXPENSE SUMMARY
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Page 2 of 3
GROSS INCOME EXPENSES
Income Sources: Dollars Cents CentsDollarsPrize/Payouts:
Bingo (including Hotball, Pickle Jar,
Cookie Jar, etc.) .................................
Pull Tabs ............................................
Punchboards ......................................
Tip Boards .........................................
Charity Game Night (Dice, Car ds, or
Wheel Games) ..................................
.
Raffle* (including 50/50)...................
Door Prize* (Paid attendance/ticket).
Water Race ........................................
Guessing Game .................................
1.
2.
3.
4.
5.
9.
6.
7.
8.
Total Gross Income (Add Lines 1-9)
10.
Bingo (including Hotball, Pickle
Jar, Cookie Jar, etc.).......................
Pull Tabs ........................................
Punchboards ..................................
Tip Boards .....................................
Charity Game Night (Dice, Car ds,
or Wheel Games) ..........................
Raffle (including 50/50) ................
Door Prize .....................................
Water Race ....................................
Guessing Game .............................
Total Prize/Payout: add Lines 1 1-
19 ..................................................
Supply Purchase
Equipment Purchase/Rental:
Bingo Game: bingo cards, sheets, pads,
monitors, blowers, etc. ...................
PPT: pull tabs, punchboards &
tip boards .........................................
Card, Dice & Wheel: playing cards, dice,
poker chips, imitation money, table layouts,
roulette wheel, spindle wheel, etc. ...........
Raffle & Door Prize: tickets, drum, cage,
etc. ............................................
Water Race & Guessing Game: tickets,
rubber ducks, etc. ...........................
Advertising ............................ 28.
Charity Gaming License Fee......... 27.
11.
13.
12.
14.
15.
16.
18.
17.
20.
19.
23.
24.
25.
22.
21.
26.
Total Expenses: add Lines 20
through 28 ....................................
29.
Net Income
Total Gross Income from Line 10
Total Expenses from Line 29 ........
Net Proceeds available for Chari-
table Purposes. (Subtract Line 31
from Line 30.) Carry this number
to Line 33 on Page 3 ....................
30.
31.
32.
FacilityRental:
Facility Rent** - lesser of $200 or
actual amount of rent paid each
day of charity gaming event. ......
DO NOT MARK OUT / CROSS OUT ANY LINE
INFORMATION OR ADD ANY LINE TO THIS FORM.
*If any part of an admission price includes a ticket or entry
into a raffle or door prize drawing, then you must determine
what portion of the cost is attributable to the ticket or entry
to the raf fle or door prize drawing, as this portion will be
considered gross income to report on line 6 and line 7.
**Facility rent may only be claimed if you actually paid rent
and supplied a rental / lease agreement with the application.
Expenses claimed may require a detailed listing upon request.
Only charity gaming activity income and expenses can be
claimed on this form.
Income and expense from only one annual license type should
be reported on each financial report.
LICENSE RENEWAL FEES
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
15,000
25,000
50,000
75,000
100,000
150,000
200,000
250,000
300,000
400,000
500,000
750,000
1,000,000
1,250,000
1,500,000
1,750,000
2,000,000
2,250,000
2,500,000
3,000,000
------------
0
15,000
25,000
50,000
75,000
100,000
150,000
200,000
250,000
300,000
400,000
500,000
750,000
1,000,000
1,250,000
1,500,000
1,750,000
2,000,000
2,250,000
2,500,000
3,000,000
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
50
100
300
400
700
1000
1,500
1,800
2,500
3,250
5,000
6,750
9,000
11,000
13,000
15,000
17,000
19,000
21,000
24,000
26,000
At least But Less Than The renewal fee is:
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Page 3 of 3
CHARITABLE CONTRIBUTIONS INFORMATION
(These amounts must have been earned from your Charity Gaming proceeds.)
33. Net proceeds from Line 32 of the Income and Expense Summary ................................................
34a. Amount from Line 33 distributed for charitable purposes ...................
These contributions must be made to or ganization(s)/(individual(s)) other than your own.
Details from these contributions need to be reported on Schedule CG-DIST.
34b. Amount from Line 33 retained for and/or spent on your organization
These funds must have been used for the lawful purpose of your organization. A detailed listing
of how these funds were spent or were set aside for a specific use should be kept with your records.
34c. Add the amounts from Lines 34a and 34b and enter total here .....................................................
35. Undistributed balance (Line 33 minus Line 34c) ..........................................................................
Cents
Dollars
33.
34a.
34b.
34c.
35.
1. Enter the Total Gross Gaming Income from line 10, page 2 on Form CG-8 .................................................................
2. Enter from line 26 on your CG-8 the allowable facility rental deduction ...........................................................................
3. Subtract line 2 from line 1 to determine your adjusted gross income total .........................................................................
$
$
$
4. Find the amount shown in #3 on
the chart to the left in order to
determine the license fee for your
next annual license. Enter the
corresponding fee here ..................
$
If you are renewing your annual event license, you must send the
amount listed above for the appropriate license with this form
along with the appropriate renewal form for your event. Make
your check from your separate and segregated charity gaming
checking account payable to: Indiana Gaming Commission.
You will need to submit a separate check for each license type.
Check this box if you are not renewing this
annual license. If you are not renewing the
annual license for this financial report, the
fee shown on line 4 is not due at this time.
