STATE OF WEST VIRGINIA 
        State Tax Department, Charitable Bingo/Raffle Unit
        P.O. Box 1143
        Charleston, WV 25324-1143

        Name

        Address                                                                                                  Account #:

        City                                                            State                 Zip

WV/BGO-3
rtL176 v.10-web SUPER, ANNUAL, LIMITED & STATE FAIR BINGO FINANCIAL REPORT
Taxpayers required to file electronically will no longer receive returns for the tax types subject to the
        mandatory requirement by mail.  Please visit www.tax.wv.gov for additional information.
                            PLEASE USE BLUE OR BLACK INK ON ALL FORMS
Report Period:              to                                            Due Date:                                Check if Annual Report

                TYPE OF LICENSE (CHECK ONE) AND NUMBER OF BINGO OCCASIONS
        ANNUAL LICENSE                                                                           LIMITED LICENSE           Number of Bingo
                                                                                                                           Occasions this Period
        ANNUAL SENIOR LICENSE                                                                    STATE FAIR LICENSE
        ANNUAL LICENSE ($20,000 OR LESS)                                                         SUPER LICENSE

                                   CALCULATION OF ENDING BALANCE
1. Total Receipts (From Schedule A Line 5)
                                                                                                                                         .
2. Total All Prizes (From Schedule B Line 5)
                                                                                                                                         .
3. Total Bingo Expenses (From Schedule C Line 8)
                                                                                                                                         .
4. Net Profit (Loss) for this Period (Line 1 minus Line 2 and Line 3)
                                                                                                                                         .
5. Beginning Balance (Unexpended Balance at End of Last Period)
                                                                                                                                         .
6. Deposits in Bingo Account
                                                                                                                                         .
7. Adjustments in Bingo Account (Attach Explanation)
                                                                                                                                         .
8. Amounts Contributed this Period:
                                                                                                                                         .
9. Ending Unexpended Balance (Line 4 + 5 +/- 6 +/- 7 - 8) (Must match checkbook)
                                                                                                                                         .
                                                         CONCESSIONS
CONCESSION OPERATOR

1. Receipts
                                                                                                                                         .
2. Expenses
                                                                                                                                         .
3. Net Profit (Loss) Line 1 minus Line 2
                                                                                                                                         .
                Complete page 2 and sign return where indicated.  Complete detailed check listing on page 3.

                MAIL TO:  WEST VIRGINIA STATE TAX DEPARTMENT
                Charitable Bingo/Raffle Unit
                P.O. Box 1143, Charleston, WV  25324-1143
                FOR ASSISTANCE CALL  (304) 558-8683
                For more information visit our web site at: www.tax.wv.gov
                File online at https://mytaxes.wvtax.gov                                                           O     2     0     0     8     0     9     0     1     W

WV/BGO-3
rtL176 v.10-web SUPER, ANNUAL, LIMITED & STATE FAIR BINGO FINANCIAL REPORT

                         PLEASE USE BLUE OR BLACK INK ON ALL FORMS

                     NAME OF BANK AND BINGO CHECKING ACCOUNT NUMBER
NAME OF BANK                                               BINGO CHECKING ACCOUNT NUMBER

                         SCHEDULE A - RECEIPTS FOR REPORTING PERIOD
1. Admission or Receipts
                                                                                                                         .
2. Sales of Supplies
                                                                                                                         .
3. Donated Prizes (Fair Market Value)
                                                                                                                         .
4. Other Receipts (Attach Itemized Sheet)
                                                                                                                         .
5. Total Receipts (Add Lines 1 through 4) Enter here and on Page 1 Line 1
                                                                                                                         .

                                             SCHEDULE B - PRIZES
1. Cash or Check
                                                                                                                         .
2. Merchandise — Cash Value at Time of Purchase
                                                                                                                         .
3. Donated Prizes (Value)
                                                                                                                         .
4. Other Prizes (Door Prizes, Winner Take All, Penny Games)
                                                                                                                         .
5. Total All Prizes (Add Lines 1 through 4) Enter here and on Page 1 Line 2
                                                                                                                         .

                                             SCHEDULE C - EXPENSES
1. Rental
                                                                                                                         .
2. Advertising
                                                                                                                         .
3. Custodial Service
                                                                                                                         .
4. Equipment & Supplies
                                                                                                                         .
5. Security Personnel
                                                                                                                         .
6. Salaries for Bingo Operators (Attach List)
                                                                                                                         .
7. Other (Explain)
                                                                                                                         .
8. Total Bingo Expenses (Add Lines 1 through 7) Enter here and on Page 1 Line 3
                                                                                                                         .
THE FINANCIAL RETURN MUST BE CERTIFIED BY A CERTIFIED PUBLIC ACCOUNTANT OR BY A LICENSED
                PUBLIC ACCOUNTANT IF SCHEDULE A LINE 5 (TOTAL RECEIPTS) EXCEEDS $50,000.

                                               AGREEMENT

I,                                           , AS AN AUTHORIZED REPRESENTATIVE OF
CERTIFY OR AFFIRM THAT THE STATEMENTS AND ITEMS ENTERED HEREIN AND ATTACHED HERETO ARE TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE.
                (Name - Type or Print)                     (Signature)                  (Date)

                  (Telephone Number)                       (Email Address)

                                               Page 2 of 4                       O     2     0     0     8     0     9     0     2     W

WV/BGO-3
rtL176 v.10-web SUPER, ANNUAL, LIMITED & STATE FAIR BINGO FINANCIAL REPORT

Account #:

Name
                     PLEASE USE BLUE OR BLACK INK ON ALL FORMS

                LISTING OF CHECKS PAID OUT OF BINGO CHECKING ACCOUNT
* NOTE: ALL CHECKS PAID OUT OF BINGO ACCOUNT MUST BE LISTED BEFORE RETURN CAN BE ACCEPTED
                     USE ADDITIONAL SHEETS IF NECESSARY
CHECK           DATE PAYEE            PURPOSE OF CHECK              DOLLAR
NUMBER                                                              AMOUNT

                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                           Page 3 of 4

WV/BGO-3
rtL176 v.10-web SUPER, ANNUAL, LIMITED & STATE FAIR BINGO FINANCIAL REPORT

                PLEASE USE BLUE OR BLACK INK ON ALL FORMS

THIS SCHEDULE MUST BE FILED WITH ALL BINGO AND SUPER BINGO FINANCIAL REPORTS
                     SCHEDULE 1
                LIST ALL WINNERS OVER $100.00 AT EACH BINGO OCCASION
                                SOCIAL                              DOLLAR
DATE            NAME ADDRESS    SECURITY                            AMOUNT
WON                             NUMBER                              WON

                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .
                                                                          .

                     Page 4 of 4