MONTHLY GAMING MACHINE TAX RETURN
CLUB

Please note this return is due within 7 days after the end of the relevant month.

Licensee:	
Month:	Licence No:	

	Turnover
$	Total Wins
$	Metered jackpots paid
$	Shortpays

$	Unmetered link jackpots paid
$	Total Payouts
B+C+D+E

$	Total Gross Revenue
A-F
$	
	A	B	C	D	E	F	G	
⅟10 Cent								
1 Cent								
2 Cent								
5 Cent								
10 Cent								
20 Cent								
$1.00								
$2.00								
SUB-TOTAL								
LESS FORFEITED UNCLAIMED LINKED JACKPOTS (FULJP) FOR THE CORRESPONDING MONTH IN PREVIOUS YEAR (FROM PAGE 2)		
			TOTAL GROSS REVENUE =  Sub-Total G   -   (FULJP)		
REVENUE	TAX RATE	TAX PAYABLE	
$1 TO $14,999	NIL	$	
$15,000 TO $24,999	15%	$	
$25,000 TO $49,999	16%	$	
ABOVE $50,000	18%	$	
Total Tax Liability (before adjustments)	$	
Adjustments
(as per statements received from Commission)	$	
TOTAL TAX PAYABLE	$	

Note: No Tax is payable where the total gross revenue
         does not exceed $14,999 and ‘Nil’ should be written
         in the following box.  Where revenue is equal to or 
         greater than $15,000 the corresponding tax rate applies.

UNCLAIMED JACKPOTS

DATE JACKPOT WON	MACHINE SERIAL NUMBER	LINK TYPE/NUMBER	AMOUNT OF MONEY UNCLAIMED - $	

				

				

				

I, ____________________________________________ of _________________________________________________
                            (print full name)                                                                                 (name of licensee)

declare that the information on this tax return form is true and correct.

____________________________(Signature)_____________________________(Position) _____/____/_____ (Date)

Important Information
Post application to: ACT Gambling and Racing Commission PO Box 214   CIVIC SQUARE   ACT   2608	

Please indicate by ticking the appropriate box which of the following will be the method of payment:
•	money order or cheque made payable to the ACT Gambling and Racing Commission; or
•	EFT/direct credit (Account name: ACT Gambling & Racing Commission Tax Collections,          BSB-062-987, Account number: 10001432); or
•	credit card (Visa or Master Card).  Please complete the required details in the area provided below.	

Payment by credit card	

Card type	  Master Card	  Visa	    Amount $ ....……..  (maximum of $3,000.00)

Card Number     Expiry Date: .…./….

Name on Card: …………………………………….…  Signature: …………………………………..

This section for office use only – finance section

Payment
Processed by: ……..…….…………………. Date: …..../……../.…….    Receipt Number: …………….
 			(Authorised Officer)