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210 W 6th Avenue * PO Box 6108 * Kennewick, WA 99336-0108 Phone (509) 585-4266 * Fax (509) 585-4383 GAMBLING TAX RETURN The tax levied on gambling activity shall be paid quarterly for the preceding three month period on or before the 31st day of January, the 30th day of April, the 31st day of July and the 31st day of October at the office of the Support Services Director as specified in Kennewick Municipal Code 3.60.040. PENALTIES AND INTEREST MAY BE ASSESSED ON THE FIRST DAY FOLLOWING THE DUE DATE. Name of Business Business Address Mailing Address State Gambling License No. TAX LEVIES I. Punchboard/Pull Tabs: Gross Receipts Less Amount Paid as Prizes ) Net Receipts Tax Due (Net Receipts X .10) II. Bingo Games: Gross Receipts Less Amount Paid as Prizes ) Net Receipts Tax Due (Net Receipts X .05) III. Card Rooms: Gross Receipts Tax Due (Gross Receipts X .10) IV. Amusement Games: Gross Receipts Less Prizes ) Net Receipts Tax Due (Net Receipts X .02) TAX DUE PENALTIES I. Late Penalty - 50% of tax due II. Interest - 1% of all taxes and penalties due for each month delinquent or portion thereof. PENALTIES DUE TOTAL TAX AND PENALTIES DUE I declare under the penalties of perjury that this return, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge is a true, correct, and complete return. Signature and Title Date A COPY OF YOUR WASHINGTON STATE GAMBLING COMMISSION REPORT MUST BE ATTACHED. Revised 1/5/2000