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 REVENUE FROM GAMING MACHINES (GRGM)
[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 GRGM [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:					

COMMUNITY CONTRIBUTIONS INFORMATION
RECORD OF CONTRIBUTIONS BY A HOTEL OR TAVERN PURSUANT TO S.165 OF THE GAMING MACHINE ACT 2004

CHARITABLE AND SOCIAL WELFARE 

(Financial year)		(Name of Venue)	

Date or period	Name of Organisation receiving benefit	Monetary or In-Kind
(M or IK)*	Specific purpose for which contribution used	Amount or value
$	

					

					

					

					

					

					
					
TOTAL CHARITABLE AND SOCIAL WELFARE AMOUNTS THIS PAGE		
TOTAL CHARITABLE AND SOCIAL WELFARE AMOUNTS ALL PAGES		

*All in-kind contributions claimed must show how the value of the contribution was worked out and be supported by evidence showing the value is based on the cost of providing the contribution or the market value of the contribution.

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COMMUNITY CONTRIBUTIONS INFORMATION
RECORD OF CONTRIBUTIONS BY A HOTEL OR TAVERN PURSUANT TO S.165 OF THE GAMING MACHINE ACT 2004

SPORT AND RECREATION

(Financial year)		(Name of Venue)	

Date or period	Name of Organisation receiving benefit	Monetary or In-Kind
(M or IK)*	Specific purpose for which contribution used	Amount or value
$	

					

					

					

					

					

					
					
TOTAL SPORT AND RECREATION AMOUNTS THIS PAGE		
TOTAL SPORT AND RECREATION AMOUNTS ALL PAGES		

*All in-kind contributions claimed must show how the value of the contribution was worked out and be supported by evidence showing the value is based on the cost of providing the contribution or the market value of the contribution.

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COMMUNITY CONTRIBUTIONS INFORMATION
RECORD OF CONTRIBUTIONS BY A HOTEL OR TAVERN PURSUANT TO S.165 OF THE GAMING MACHINE ACT 2004

NON-PROFIT ACTIVITIES

(Financial year)		(Name of Venue)	

Date or period	Name of Organisation receiving benefit	Monetary or In-Kind
(M or IK)*	Specific purpose for which contribution used	Amount or value
$	

					

					

					

					

					

					
					
TOTAL NON-PROFIT ACTIVITIES AMOUNTS THIS PAGE		
TOTAL NON-PROFIT ACTIVITIES AMOUNTS ALL PAGES		

*All in-kind contributions claimed must show how the value of the contribution was worked out and be supported by evidence showing the value is based on the cost of providing the contribution or the market value of the contribution.

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COMMUNITY CONTRIBUTIONS INFORMATION
RECORD OF CONTRIBUTIONS BY A HOTEL OR TAVERN PURSUANT TO S.165 OF THE GAMING MACHINE ACT 2004

COMMUNITY INFRASTRUCTURE

(Financial year)		(Name of Venue)	

Date or period	Name of Organisation receiving benefit	Monetary or In-Kind
(M or IK)*	Specific purpose for which contribution used	Amount or value
$	

					

					

					

					

					

					
					
TOTAL COMMUNITY INFRASTRUCTURE AMOUNTS THIS PAGE		
TOTAL COMMUNITY INFRASTRUCTURE AMOUNTS ALL PAGES		

*All in-kind contributions claimed must show how the value of the contribution was worked out and be supported by evidence showing the value is based on the cost of providing the contribution or the market value of the contribution.

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COMMUNITY CONTRIBUTIONS INFORMATION
RECORD OF CONTRIBUTIONS BY A HOTEL OR TAVERN PURSUANT TO S.165 OF THE GAMING MACHINE ACT 2004

WOMEN’S SPORT 

(Financial year)		(Name of Venue)	

Date or period	Name of Organisation receiving benefit	Monetary or In-Kind
(M or IK)*	Specific purpose for which contribution used	Actual Amount or Value
$	Adjusted Amount 
(Actual x 4/3)
$	

						

						

						

						

						

TOTAL WOMEN’S SPORTS AMOUNTS THIS PAGE		
TOTAL WOMEN’S SPORTS AMOUNTS ALL PAGES		

*All in-kind contributions claimed must show how the value of the contribution was worked out and be supported by evidence showing the value is based on the cost of providing the contribution or the market value of the contribution.

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