Gambling and Racing Control Act 1999, s 53D
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 Abbreviations Must Have An Expansion Provided.

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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 Abbreviations Must Have An Expansion Provided.

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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 Abbreviations Must Have An Expansion Provided.

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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 Abbreviations Must Have An Expansion Provided.

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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 Abbreviations Must Have An Expansion Provided.

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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

PROBLEM GAMBLING 

(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 PROBLEM GAMBLING AMOUNTS THIS PAGE		
TOTAL PROBLEM GAMBLING AMOUNTS ALL PAGES		

*All Abbreviations Must Have An Expansion Provided.

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