"Bingo-Raffle Supplier Licensee Quarterly Report Form" - Colorado

Bingo-Raffle Supplier Licensee Quarterly Report Form is a legal document that was released by the Colorado Secretary of State - a government authority operating within Colorado.

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Download "Bingo-Raffle Supplier Licensee Quarterly Report Form" - Colorado

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STATE OF COLORADO
OFFICE OF THE SECRETARY OF STATE -- LICENSING DIVISION
1700 Broadway, Suite 200
Denver, Colorado 80290
Telephone : (303)894-2200, extension 6412
BINGO-RAFFLE SUPPLIER LICENSEE QUARTERLY REPORT FOR _______ QUARTER 20_____
Quarterly reports must be filed with the Secretary of State no later than April 30,
July 31, October 31, and January 31 for the preceeding calendar quarter of each year.
1.
NAME OF SUPPLIER___________________________________________________________________
2.
CURRENT LICENSE NUMBER____________________________________________________
3.
STREET ADDRESS______________________________________________________________
4.
CITY ________________________________ STATE _________________ ZIP _____________
5.
TELEPHONE ____________________ CONTACT PERSON __________________________________
6.
SUPPLIERS COLORADO AGENT(s) :
NAME
LICENSE #
COMPLETE ADDRESS
7 CALCULATION OF QUARTERLY FEE DUE (2.0% OF ALL SALES FOR QUARTER)
ITEM 8
(BINGO) TOTAL (from attachment 1)
$
-
+ ITEM 9
(PULLTAB) TOTAL (from attachment 2)
$
-
+ ITEM 10 (OTHER) TOTAL (from attachment 3, 3A)
$
-
FEE DUE*
GRAND TOTAL FOR QUARTER
$
-
x .02 =
$
Due with report. Make check payable to "Colorado Secretary of State".
REPORT VERIFICATION
I, ____________________________________, solemnly affirm under penalty of perjury as defined in section
18-8-503, Colorado Revised Statutes and punishable by law that I am the owner _____ or chief executive
officer _____ of the licensee herein, that I know the contents of this Quarterly Report, including any and all
attachments and supplements with or in it, and that all matters set forth in it are true, accurate, and complete.
Affirmed this _____ day of __________________, 20____
___________________________________
Signature
___________________________________
Title
STATE OF COLORADO
OFFICE OF THE SECRETARY OF STATE -- LICENSING DIVISION
1700 Broadway, Suite 200
Denver, Colorado 80290
Telephone : (303)894-2200, extension 6412
BINGO-RAFFLE SUPPLIER LICENSEE QUARTERLY REPORT FOR _______ QUARTER 20_____
Quarterly reports must be filed with the Secretary of State no later than April 30,
July 31, October 31, and January 31 for the preceeding calendar quarter of each year.
1.
NAME OF SUPPLIER___________________________________________________________________
2.
CURRENT LICENSE NUMBER____________________________________________________
3.
STREET ADDRESS______________________________________________________________
4.
CITY ________________________________ STATE _________________ ZIP _____________
5.
TELEPHONE ____________________ CONTACT PERSON __________________________________
6.
SUPPLIERS COLORADO AGENT(s) :
NAME
LICENSE #
COMPLETE ADDRESS
7 CALCULATION OF QUARTERLY FEE DUE (2.0% OF ALL SALES FOR QUARTER)
ITEM 8
(BINGO) TOTAL (from attachment 1)
$
-
+ ITEM 9
(PULLTAB) TOTAL (from attachment 2)
$
-
+ ITEM 10 (OTHER) TOTAL (from attachment 3, 3A)
$
-
FEE DUE*
GRAND TOTAL FOR QUARTER
$
-
x .02 =
$
Due with report. Make check payable to "Colorado Secretary of State".
REPORT VERIFICATION
I, ____________________________________, solemnly affirm under penalty of perjury as defined in section
18-8-503, Colorado Revised Statutes and punishable by law that I am the owner _____ or chief executive
officer _____ of the licensee herein, that I know the contents of this Quarterly Report, including any and all
attachments and supplements with or in it, and that all matters set forth in it are true, accurate, and complete.
Affirmed this _____ day of __________________, 20____
___________________________________
Signature
___________________________________
Title