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210 W 6th Avenue * PO Box 6108 * Kennewick, WA 993360108 Phone (509) 5854266 * Fax (509) 5854383 GAMBLING TAX RETURN The tax levied on any card playing shall be paid on or before the last calendar day of the month for the preceding month or a portion thereof. The tax levied on any punchboards or pulltabs, bingo games and amusement games 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 Treasurer 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 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 – (minimum penalty is $25) 120 days past due 10% 21 or more days past due 15% 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 (WSGC) REPORTS MUST BE SUBMITTED ON THE SAME REPORTING SCHEDULE AS REQUIRED BY THE STATE. WSGC LICENSE Revised 04/15/2011