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REVISED 4/1/2016 City of Puyallup Quarterly Gambling Tax Report Charitable/Not for Profit Enterprises COMPANY NAME: FEDERAL TAX ID: CONTACT PERSON: ADDRESS: PHONE: REPORTING PERIOD: THROUGH INSTRUCTIONS: Please complete and return this form with remittance to the City of Puyallup, P.O. Box 84911, Seattle, WA 98124-6211. Please attach a copy of the State Gambling Commission Report for this period. DUE DATE: In accordance with Puyallup Municipal Code Chapter 5.68, gambling taxes are due quarterly by the 20th day of the month following the end of each calendar quarter. The Puyallup Municipal Code is available online at www.cityofpuyallup.org . PENALTY: Failure to pay taxes owed by the due date will result in the assessment of a penalty of 5% of the taxes due per month. PUNCHBOARD/PULLTAB ACTIVITY: Month: Month: Month: Totals Punchboard Gross Receipts: Pulltab Gross Receipts: Total Gross Receipts: Less Prizes Paid (Cash/Merchandise): Net Punchboard/Pulltab Receipts: Tax Owed (10% of Net Receipts) BINGO/RAFFLE ACTIVITY: Month: Month: Month: Totals Bingo/Raffle Gross Receipts: Less Prizes Paid (Cash/Merchandise): Less Exemption (first $10,000 net each year is exempt): Net Bingo/Raffle Receipts: Tax Owed of Net Receipts): CARD GAMES: Month: Month: Month: Totals Card Games Gross Receipts: Tax Owed (20% of Gross Receipts) PENALTY (IF ANY): $ TOTAL TAXES DUE: $ I hereby certify that the above Quarterly Gambling Tax Report is a true and complete record of the transactions which occurred. Signed: Date: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00