Transcription of LICENSED CHARITABLE GAMING FACILITY …
1 Reviewed By:CG-FAC11/13 Quarter: 1 __ 2 __ 3 __ 4 __ (check one)Calendar Year: _____ FACILITY NAME: _____ license NO. FAC-_____ LICENSEE NAME: _____ MAILING ADDRESS (Licensee): _____ LOCATION OF FACILITY : Street Address: _____ City: _____ County: _____ Under penalty of perjury, I declare that I have examined this report, including any accompanying schedules and attachments, and to the best of my knowledge and belief it is a true, correct, and complete report.
2 Declaration of preparer (other than organization official) is based on all available EXECUTIVE OFFICER (Print Name)CHIEF EXECUTIVE OFFICER (Signature)TITLEDATENAME (Print Name)NAME (Signature)TITLEDATEVISIT OUR WEBSITE AT CHARITABLE GAMING FACILITY QUARTERLY REPORTREPORT DUE BY APRIL 30TH, JULY 31ST, OCTOBER 31ST, OR JANUARY 31 STSIGNATURE AND VERIFICATIONCG-FACPAGE 211/13 NAMEJOB TITLESOCIAL SECURITY NUMBERON PREMISES DURING GAMING SESSIONS (YES/NO)TOTAL NUMBER OF FACILITY EMPLOYEESOR CONTRACTEESE mployees or Contractees of LICENSED FACILITY (attach additional pages if needed)CG-FACPAGE 311/13 organization NameOrganization license # Total Rent Owed During Quarter Total Rent Paid During Quarter Rent Due 30 Days Past Due 60 Days Past Due 90 Days Past Due Total Amount Past Due PAST DUE ORGANIZIATIONSCG-FACPAGE 411/13 organization NameOrganization license #Date of EventTime of EventType of EventRent ChargedQUARTERLY FACILITY SPECIAL EVENTS SUMMARY
