GAMING MACHINE ACT 2004		
		                      Form made pursuant to s 53D of Gambling and Racing Control Act 1999		

	
MONTHLY GAMING MACHINE TAX RETURN 	
HOTEL/TAVERN	
Please note this return is due within 7 days after the end of the relevant month	
SECTION 1	DETAILS OF LICENSEE	
Name of Licensee	 	Licence No.		 	
Trading Name	 	Month	 	
		
SECTION 2	GROSS REVENUE	
 	Turnover
$	Total Wins
$	Metered Jackpots Paid
$	Shortpays
$	Unmetered Link Jackpots Paid
 $	Multi–User Link Contribution
$	Total Payouts B+C+D+E+F 
 $	Sub-Total Gross Revenue A-G
$	
 	A	B	C	D	E	F	G	H	
⅟10 Cent		 		 	 			 	
1 Cent	 	 	 	 	 		 	 	
2 Cent	 	 	 	 	 		 	 	
5 Cent	 	 	 	 	 		 	 	
10 Cent	 	 	 	 	 		 	 	
20 Cent	 	 	 	 	 		 	 	
$1.00	 	 	 	 	 		 	 	
$2.00	 	 	 	 	 		 	 	
Sub - Total	 	 	 	 	 		 	 	
Less I (Forfeited unclaimed linked jackpots for the corresponding month in previous year – from page 2)	 	
	Total Gross Revenue = Sub-Total H - I		
		
SECTION 3	TAX PAYABLE	
	Total Tax Liability @ 25.9% (before adjustments)	$	
	Adjustments (as per statements received from Commission)	$	
	Total Tax Payable	$	
		
SECTION 4	TOTAL AMOUNT PAYABLE	
			Add I+J   (Forfeited unclaimed amounts for the corresponding month in previous year  - from page 2)	$	
			Total Amount Payable	$	

	2nd floor, Canberra Nara Centre, 1 Constitution Avenue, Canberra City 2601	
	PO Box 214 CIVIC SQUARE ACT 2608	
AF2009-114	Homepage: http://www.gamblingandracing.act.gov.au	

Gaming Machine Act 2004							
Monthly Gaming Machine Tax Return - Club						
								
SECTION 5	UNCLAIMED UNMETERED LINKED JACKPOTS	
(s 143 Gaming Machine Act 2004)	
Date Jackpot Won	Machine Serial Number	Link Type/Number	Amount Unclaimed in $	
 	 	 	$	
 	 	 	$	
 	 	 	$	
 	 	 	$	
 	 	 	$	
 	I: Total to be remitted to Commission	$	
								
SECTION 6	UNCLAIMED TICKETS	
(s 33 Gaming Machine Regulation 2004)	
Date Ticket Issued 	Machine Serial Number	Ticket Identification Number	Amount Unclaimed in $	
 	 	 	$	
 	 	 	$	
 	 	 	$	
 	 	 	$	
 	 	 	$	
 	J: Total to be remitted to Commission	$	
	
SECTION 7	DECLARATION	
I,____________________________________________                                                                                                                                                         	of__________________________________________________                                                                                                            	
(print full name)	(name of licensee)	
declare that the information on this form is true and correct.			 	
	(Signature)			(Position)	 	(Date)	

								

Gaming Machine Act 2004							
Monthly Gaming Machine Tax Return - Club						
IMPORTANT INFORMATION	
 									 	
Post return 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. 
•	EFT/direct credit (Account name: ACT Gambling and Racing Commission Tax Collections, 
BSB 062-987 Account Number 10001432; or
•	credit card (Visa or Mastercard). Please complete the required details in the area provided below.	

PAYMENT BY CREDIT CARD	
										
Card Type	oMastercard	oVisa	Amount $..................	(maximum $3,000.00)	

	
Card No. ____ ____ ____ ____  ____ ____ ____ ____  ____ ____ ____ ____  ____ ____ ____ ____  	
								
					Expiry Date	         /          /   		
Name on Card:……………………………………………Signature:………………………………………………	

THIS SECTION FOR OFFICE USE ONLY - FINANCE SECTION	
 									 	
Payment Processed by:	…………………………………………	Date	    /     /   	Receipt Number:	……………..	
 	(Authorised Officer)