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CITY OF BURLINGTON 833 South Spruce Street I Burlington, WA 98233 GAMBLING TAX REMITTANCE FORM Quarter Establishment, Association, or Mailing TAX COMPUTATION: A. RAFFLES AND BINGO GAMES: (Exempt: Any bonafide charitable or non-profit organization as defined in RCW 9.46.0209 which organization has no paid operating or management personnel: Gross Receipts for Quarter Bingo Only: Less: All prizes Raffles Only: Less: All prizes Net Receipts Taxable Tax Due: (Net Receipts Taxable @ B. PUNCHBOARDS AND PULLTABS Gross Receipts for Quarter Gross Receipts X 4% (for profit only) = DUE Charitable/Non-profit Organizations: Gross Receipts Less All Cash and Merchandise Prizes Taxable Amount = X 8% = TAX DUE C. CARD ROOMS Gross Receipts for Quarter Tax Due: (Gross Receipts @ E. A THROUGH D TOTAL TAX DUE: F. LATE PENALTIES AND INTEREST ($5.00 MINIMUM) 1-10 Days 6% of tax due, 11-20 days 8% of tax due, 21-31 days 10% of tax due, 32-60 days 11% tax due. Days Delinquent X total tax due In addition to penalty, interest will be charged @ 1% of tax due for each 30 day period of portion thereof Total Penalties/Interest G. Total Lines of E and F, Total Tax Due With Penalties and Interest File report on or before last day of the month of the next succeeding quarter in which tax is accrued, January 31, April 30, July 31, October 31, of each year. Attach: Copy of quarterly report to the Washington State Gambling Commission for period which tax was accrued. State Gambling Tax # Punchboards/Pulltab I swear and affirm that the information given in the return is true, accurate, and complete.