MONTHLY GAMING MACHINE RETURN
CLUB

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 LIABILITY

Electronic Funds Transfer to the ACT Gambling and Racing Commission – Tax Collections Account:
BSB: 032-777
Account Number: 002220
Reference: [Insert Licence Number]

PART B – UNCLAIMED UNMETERED LINKED JACKPOTS

Electronic Funds Transfer to the ACT Gambling and Racing Commission – Unclaimed Monies Account:
BSB: 032-777
Account Number: 001914
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 Account:
BSB: 032-777
Account Number: 001922
Reference: [Insert Licence Number]

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

AF2014-126

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 Contributions $	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	
Revenue	Tax Rate	Tax Payable	
$1 to $14,999.99	NIL	NIL	
$15,000 to $24,999.99	15%	S	
$25,000 to $49,999.99	17%	$	
$50,000 and above	21%	$	
Total Tax Liability (Before adjustments)	$	
Adjustments (As per statements received from Commission)	$	
Total Tax Payable
BSB: 032-777 Account Number: 002220	$	

THIS SECTION FOR OFFICE USE ONLY

Payment Received:  .....................................             Date          /                 /                Receipt Number:........................
                                     (authorised Officer)	

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
$	

				

				
Total Amount Payable
BSB: 032-777 account Number: 001914	$	
		
THIS SECTION FOR OFFICE USE ONLY

Payment Received:  .............................................    Date          /                 /                Receipt Number:........................
                                     (authorised Officer)	

PART C	PROBLEM GAMBLING ASSISTANCE FUND LEVY	

Total Gross Gaming Machine Revenue (from Part A of this form)	$	
Total Levy Liability @ 0.6% (before adjustment)	$	
Adjustments (as per statements received from Commission)	$	
Total Levy Payable
BSB: 032-777 Account Number: 001922	$	
		
THIS SECTION FOR OFFICE USE ONLY

Payment Received:  .............................................    Date          /                 /                Receipt Number:........................
                                     (authorised Officer)	

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) _________________