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

MONTHLY GAMING MACHINE RETURN HOTEL/TAVERN

Please ensure completed form, together with the associated payments, is received by the
Commission by the 7th day after the end on the month.

POST:

ACT Gambling and Racing Commission
PO Box 214
CIVIC SQUARE  ACT  2608

FAX:	(02) 6207 7372
EMAIL:	gaming.operations@act.gov.au

PART A  - GAMING MACHINE TAX LIABILTY

Electronic Funds Transfer to the ACT Gambling and Racing Commission – Tax
Collections Account: BSB: 062-987
Account Number: 1000 1432
Reference: [Insert Licence Number]

PART B  - UNCLAIMED PRIZES

Electronic Funds Transfer to the ACT Gambling and Racing Commission - Unclaimed
Monies:
BSB: 062-987
Account Number: 1001 9229
Reference: [Insert Licence Number]

PART C  - PROBLEM GAMBLING ASSISTANCE FUND LEVY

Electronic Funds Transfer to the ACT Gambling and Racing Commission - Problem
Gambling Assistance Fund: BSB: 062-987
Account Number: 1001 9982
Reference: [Insert Licence Number]

Note: If payment is by cheque, three separate cheques made payable to the ACT Gambling and Racing Commission are required.

AF2011-101

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

Gaming Machine Act 2004
Monthly Gaming Machine Return - Hotel/Tavern

PART A	MONTHLY GAMING MACHINE TAX RETURN

Details of Licensee	
Name of
Licensee		Licence
No.		
Trading
Name		
Month		

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	

1/10 Cent									

1 Cent									

2 Cent									

5 Cent									

10 Cent									

20 Cent									

50 Cent									

$1.00									

$2.00									
Sub- Total									
Less (Forfeited unclaimed linked jackpots for the corresponding month in previous year - from page 3)		
	Total Gross Revenue		

Tax Payable	

Total Tax Liability @ 25.9% (before adjustments)	
$	

Adjustments (as per statements received from Commission)	
$	
Total Tax Payable
BSB: 062-987 Account Number: 10001432	
$	

THIS SECTION FOR OFFICE USE ONLY

Payment Received:

……………………………….....	Date	/	/ (Authorised Officer)

Receipt Number: …………............

Gaming Machine Act 2004
Monthly Gaming Machine Return - Hotel/Tavern

PART B

UNCLAIMED PRIZES

Details of Licensee	
Name of
Licensee		Licence
No.		
Trading
Name		
Month		

Unclaimed Unmetered Linked Jackpots	
(s 143 Gaming Machine Act 2004)	

Date Jackpot Won	
Machine Serial Number	
Link Type/Number	Amount Unclaimed
$	
			
$	
			
$	
			
$	
			
$	
			
$	
			
$	
B(i): Total to be remitted to Commission for Unclaimed Unmetered Linked Jackpots	
$	

Unclaimed Tickets	
(s 33 Gaming Machine Regulation 2004)	

Date Ticket Issued	
Machine Serial Number	
Ticket Identification Number	Amount Unclaimed
$	
			
$	
			
$	
			
$	
			
$	
			
$	
			
$	
			
$	
			
$	
			
$	
			
$	
B(ii): Total to be remitted to Commission for Unclaimed Tickets	
$	

Amount Payable
Total Amount Payable [B(i) + B(ii)]	$
BSB: 062-987 Account Number:10019229

THIS SECTION FOR OFFICE USE ONLY

Payment Received:

……………………………….....	Date	/	/ (Authorised Officer)

Receipt Number: …………............

Gaming Machine Act 2004
Monthly Gaming Machine Return - Hotel/Tavern

PART C

PROBLEM GAMBLING ASSISTANCE FUND LEVY

Details of Licensee	
Name of
Licensee		Licence
No.		
Trading
Name		
Month		

Total Gross Gaming Machine Revenue (From part A of this form)	$	
Total Levy Liability @ 0.6% (before adjustments)	$	
Adjustments (as per statements received from Commission)	$	
Total Levy Payable
BSB: 062-987 Account Number: 10019982	
$	

PART D	DECLARATION	

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

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

(Signature) 	(Position) 	(Date)  		

THIS SECTION FOR OFFICE USE ONLY

Payment Received:

……………………………….....	Date	/	/ (Authorised Officer)

Receipt Number: …………............