Form 35 "Nebraska Class I Bingo Annual Report" - Nebraska

Form 35 is a Nebraska Department of Revenue form also known as the "Nebraska Class I Bingo Annual Report". The latest edition of the form was released in February 1, 2018 and is available for digital filing.

Download an up-to-date Form 35 in PDF-format down below or look it up on the Nebraska Department of Revenue Forms website.

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N E B R A S K A D E P A R T M E N T O F R E V E N U E
2017-2018
Nebraska
Class I Bingo
Annual Report
Form 35
C H A R I T A B L E
G A M I N G
1
9-012-2018
N E B R A S K A D E P A R T M E N T O F R E V E N U E
2017-2018
Nebraska
Class I Bingo
Annual Report
Form 35
C H A R I T A B L E
G A M I N G
1
9-012-2018
Important — Please Read
This booklet contains the annual reporting forms to be completed and filed with the Nebraska Department of
Revenue (Department) by any nonprofit organization which held a Class I bingo license in Nebraska during
the period July 1, 2017 through June 30, 2018. The
Nebraska Bingo Act
requires the organization to make
a complete, true, and accurate accounting to the Department on an annual basis of its bingo gross receipts.
A copy of the report must also be submitted to the organization’s membership. The report must be filed on the
reporting forms provided in this report, and must include:
an accounting of the organization’s bingo gross receipts;
the amount awarded in prizes;
the value of donated prizes;
lawful purpose usages of any bingo profits; and
a breakdown of expenses.
All parts of the annual report must be completed and filed with the Department by August 15, 2018. If the
organization does not intend to renew its bingo license, a final report must be filed within 45 days from the
expiration date of the license. In addition, a bingo revenue status report is required to be filed each year by August 15
until all profits from the conduct of bingo have been disbursed. Instructions for completing each section of this
report are printed on each form. Failure to file a complete, true, and accurate report or not filing the report
by the due date are violations of the Nebraska Bingo Act and may jeopardize an organization’s eligibility for
license renewal and/or result in an administrative fine up to $1,000.
If you award coupons redeemable for bingo paper or hard cards as bingo or promotional prizes, the fair market
value of that paper or hard cards must be recorded on line 1c, 3b, and/or 15b. The fair market value (selling
price) of coupons redeemable for bingo paper or hard cards awarded as a bingo or promotional prize must be
included in the bingo gross receipts and is subject to the bingo tax.
Before filing the annual report, please perform these
procedures to ensure accuracy.
1. Reconcile Bingo Receipts to Bank Deposits
A. On page 1, subtract line 2a from line 1d to determine the amount of cash which should have been
available for deposit.
B. On page 2, add line 13 to line 7, and subtract lines 12 and 14 to find bank deposits from bingo sales
for the period.
C. Compare the amounts found in steps A and B above. Attach a written explanation for any significant
discrepancies, and enter the amount as an adjustment on line 16, page 1.
2. Reconcile Bingo Expenses and Lawful Purpose Disbursements to Bank Disbursements
A. Add lines 2b through 16 (excluding lines 2d, 3a, and 3b) of page 1 to lines 5 and 15 of page 2 to determine
the amount which was used for bingo expenses, lawful purpose disbursements, and other expenditures.
If any adjustment was made on line 16 for overages or shortages, it should not be included in
this calculation.
B. Compare the amount found in step A above to line 10 of page 2. If there is a significant discrepancy,
review your records and correct the annual report.
3. Compare Bank Balances
Make sure that the July 1, 2017 beginning bank balance is the same as the June 30, 2017 ending bank
balance from the previous annual report. If there is a discrepancy, please attach a written explanation.
If you have any questions or need further assistance, please contact Brenda Bergstrom at 308-672-0584 or Gail
Ross at 402-471-5955. You may also call us toll free at 877-564-1315.
You may file online at https://charitablegaming.nebraska.gov.
revenue.nebraska.gov/gaming
2
Nebraska Bingo Annual Report
FORM
35
For the reporting period July 1, 2017 through June 30, 2018 or the short period
Page 1
beginning ____________________ , 20______ and ending ____________________ , 20______.
Organization’s Name
Street or Other Mailing Address
City or Town
State
Zip Code
Nebraska ID Number
Federal ID Number
Location of Bingo Game
35 —
Bingo Income and Expenses (Do not include lawful purpose disbursements.)
1 Gross receipts: a Bingo receipts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a
b Bingo supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1b
c Value of bingo paper or hard cards purchased with coupons
1c
d Total (line 1a plus line 1b minus line 1c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1d
2 Prizes paid:
a Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b
c Merchandise (organization’s cost) . . . . . . . . . . . . . . . . . . 2c
d Total (add lines 2a through 2c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2d
3 Values: a Value of donated prizes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3a
b Value of coupons redeemable for bingo paper or hard cards
awarded as bingo prizes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3b
4 Gross compensation of bingo chairpersons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (variable)
4
5 Gross compensation of bingo workers and pickle card sellers at the bingo occasions . . . . . (variable)
5
6 Compensation for legal, bookkeeping, and janitorial services . . . . . . . . . . . . . . . . . . . . . . . (variable)
6
7 Cost of security services at the bingo occasions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (variable)
7
8 Rent — Bingo location, including furniture and fixtures (see instructions) . . . . . . . . . . . . . . . . . (fixed)
8
9 Rent — Bingo equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (fixed)
9
10 Purchases of bingo equipment (include disposable bingo paper and hard cards) . . . . . . . . . . (fixed) 10
11 Purchases of bingo supplies (daubers, tape, glue sticks, etc .) (see instructions) . . . . . . . . . . . . . . . . . 11
12 Cost of utilities for bingo occasions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (fixed) 12
13 Bingo license fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (fixed) 13
14 Bingo taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Costs: a Cost of advertising for bingo occasions (include total cost of promotional prizes) (variable) 15a
b Cost of promotional prizes included in line 15a . . . . . . . . . . . . . . . 15b
16 Other bingo expenses (attach an itemized list of expenses and the amounts) .
Do NOT include lawful purpose disbursements reported on Schedule I (page 2) . . . . . . . . . (variable) 16
17 Total bingo prizes and expenses (total of lines 2d through 16) (Do not include lines 3a, 3b, and 15b .) . . . 17
18 Net bingo profit (line 1d minus line 17) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Under penalties of law, I declare that as an officer or utilization of funds member, I have examined this report, including accompanying
schedules and statements, and to the best of my knowledge and belief, it is complete, true, and accurate .
This report will be/was made available to the organization's membership on ___________________________ .
Date
sign
here
Signature of Officer
Date
Print Name of Officer
Title
Daytime Phone Number
Signature of Preparer
Date
Daytime Phone Number
Print Name of Preparer
Address
City/State
Zip Code
Signature of Utilization of Funds Member
Daytime Phone Number
Email Address of Utilization of Funds Member or Preparer, if different
This report, related schedules, and itemized lists are due by August 15, 2018 .
Mail to: Nebraska Department of Revenue, Charitable Gaming Division, PO Box 94855, Lincoln, NE 68509-4855.
3
Instructions
When and Where to File. The annual report for the period July 1, 2017 to June 30, 2018 must be filed with
the Nebraska Department of Revenue (Department) by August 15, 2018. If the organization’s current license
expires September 30, 2018 and it does not intend to renew its license, it must file a final report for the period
July 1, 2018 to September 30, 2018 within 45 days of the expiration date of the license. That final report should
reflect three months of bingo activity and the final distribution of all bingo profits or a plan for the disbursement
of any remaining funds. The organization must continue to submit bingo revenue status reports each year by
August 15 until all bingo profits have been disbursed for lawful purposes.
If the organization does not intend to renew its license, has completed all bingo activity by June 30 of
any year, and has disbursed all of its bingo profits for lawful purposes, write “Final Report” at the top of
the report.
Reporting Period. The annual report is to cover the organization’s bingo activities from July 1 through
June 30. If the organization is filing a short period report, the beginning and ending dates of the reporting
period must be entered in the space provided at the top of the report. If all profits from the conduct of
bingo have been disbursed during this reporting period and no further bingo activity is anticipated, write
“Final Report” at the top of page 1.
Accounting Method. The annual report is to be prepared based upon the organization’s accounting basis:
cash; accrual; or other.
Specific Instructions
Line 1a. Enter the gross receipts derived from the conduct of bingo (for example, receipts from the sale or
rental of bingo paper, hard cards, bingo card monitoring devices, admissions and the value of bingo paper
or hard cards purchased with coupons awarded as bingo prizes or promotional prizes).
Line 1b. Enter all receipts from the sale of bingo supplies (for example, daubers, glue sticks, tape).
Line 1c. Enter the value (selling price) of bingo paper or hard cards purchased with coupons awarded as
bingo prizes or promotional prizes.
Line 2. Enter the actual cost of all prizes paid. Do not include the value (selling price) of coupons redeemable
for bingo paper or hard cards awarded as bingo prizes (which are shown on line 3b).
Line 3a. Enter the value (selling price) of donated prizes awarded at the bingo occasions.
Line 3b. Enter the value (selling price) of coupons redeemable for bingo paper or hard cards awarded as
bingo prizes.
Line 4. Enter the gross compensation paid to the chairpersons for services performed related to the conduct
of bingo.
Line 5. Enter the gross compensation paid to bingo workers and pickle card sellers working at the bingo
occasions. Payroll taxes withheld must also be included (i.e., state and federal income tax withholding and
Social Security).
Line 6. Enter the gross compensation paid to all individuals for services performed related to the conduct
of bingo which are not provided for in any lease agreement.
Line 7. Enter the cost of security services for the conduct of bingo. Generally, security services are services
provided by a licensed detective agency or by off-duty law enforcement officers during the conduct of the
bingo occasions.
Line 8. Enter the amount paid for rental of the bingo premises. Include maintenance, repairs, and janitorial
expenses included in the lease agreement.
4
Line 9. Enter the amount paid for the rental of bingo equipment utilized in the conduct of bingo. Bingo
equipment includes, but is not limited to: blower machines; flash boards; bingo card monitoring devices; and other
similar equipment.
Line 10. Enter the cost of bingo equipment purchased including hard cards, disposable bingo paper, and
bingo card monitoring devices.
Line 11. Enter the cost of bingo supplies purchased for resale. If the organization gives away bingo supplies
as promotional prizes, the cost of those supplies must be recorded on line 15a. If any bingo supplies are
given away or sold at a discount, the cost of bingo supplies given away and/or the amount of the discount
must be recorded on line 15a. Example. If daubers are purchased for $1.00 and sold for $1.25, enter $1.00
on line 11; if daubers are purchased for $1.00 and given away, enter $1.00 on line 15a; or if daubers are
purchased for $1.00 and sold for $0.75, enter $0.75 on line 11 and $0.25 on line 15a.
Line 12. Enter the cost of utilities associated with the conduct of bingo. If utility costs cannot be separately
measured, the cost may be allocated on the basis of time (a ratio of time spent to conduct the bingo activity
to the total time spent for all activities). Include with the annual report a complete description of the allocation
method utilized.
Line 15a. Enter the cost of advertising and promotional prizes awarded at the bingo occasions. Do not
include the value (selling price) of coupons redeemable for bingo paper or hard cards awarded as promotional
prizes (which are shown on line 15b).
Line 15b. Enter the cost of promotional prizes.
Line 16. Enter the amount paid for all other expenses associated with the conduct of bingo not previously
identified in this report. This includes the employer’s share of payroll taxes, and also repair and maintenance
expenses not already covered in a current lease agreement. This line may also be used to show any shortages
or overages in bingo receipts and interest earned in the bingo checking account. Attach an itemized schedule
to the annual report identifying the nature of each expense and the corresponding amount.
Authorized Signatures. The annual report must be signed by an officer of the organization or other
individual authorized to sign by a
Power of Attorney, Form
33, on file with the Department and by the
organization’s Utilization of Funds Member. If a person other than the Utilization of Funds Member
prepares the report, the preparer must also sign in the space provided.
Allowable Expense Calculation
Total variable expenses (lines 4 thru 7, + 15a - 15b + 16) $
= . _________This amount is not to exceed 14% (.14).
Bingo gross receipts (line 1a)
$
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