Quarterly Gambling Tax Return Form
Activity
Gross Receipts
Cash & Prizes
Paid Out
Receipts Less
Cash / Prizes
Paid
Taxable
Revenue
Tax
Rate
Tax Due
Bingo 5%
Raffles 5%
Fund Raising
Events
10%
Amusement
Game
2%
Punch-Boards 5%
Pull Tabs 5%
Cardrooms 6%
x 1% x
QUARTERLY GAMBLING TAX RETURN
Year Quarter For Official Use Only
Name
Address
DATE REC’D
REC. #
WSGC#
TOTAL TAX
+
TO CALCULATE INTEREST:
TOTAL
TAX
MONTHLY
INTEREST RATE
NUMBER OF MONTHS
DELINQUENT
= LATE
INTEREST
TOTAL TAX & INTEREST DUE
I Certify under penalty of perjury that the information above is correct and complete to the best of my knowledge and belief.
SIGNATURE DATE
Revised 6/2/2015