Gambling and Racing Control Act 1999, s 53D
COMMUNITY CONTRIBUTIONS INFORMATION
FINANCIAL REPORT BY A HOTEL OR TAVERN
(Pursuant to section 166 of the Gaming Machine Act 2004)

APPLICABLE FINANCIAL YEAR:  ____________________________		
					
Licence Number:			Venue:		

		$	
A.		GROSS GAMING MACHINE REVENUE (GGMR)
[Total after deducting players’ winnings (excluding linked jackpots) and any amount set aside under a linked-jackpot arrangement for the payment of jackpot payouts]		
B.	TOTAL VALUE OF CLAIMED COMMUNITY CONTRIBUTIONS		
C.	CLAIMED COMMUNITY CONTRIBUTIONS EXPRESSED AS A % OF GGMR [B/A x 100]		
D.	VALUE OF CONTRIBUTIONS TO REGISTERED POLITICAL PARTIES AND THEIR ASSOCIATED POLITICAL ENTITIES 		

Signature of person submitting report:			Date:	                /            /	
					
Position in corporation: