MONTHLY GAMING MACHINE RETURN – HOTEL/TAVERN

Please ensure completed form, together with the associated payments, is received by the Commission at gaming.operations@act.gov.au by the 7th day after the end of the tax period.

Payments associated with this return are to be made by Electronic Funds Transfer to the ACT Gambling and Racing Commission:

PART B – GAMING MACHINE TAX LIABILITY
Tax Collections Account:
BSB: 032-777
Account Number: 002220
Reference: [Insert Certificate of Authorisation Number]
	PART C – PROBLEM GAMBLING ASSISTANCE FUND LEVY
Problem Gambling Assistance Fund Account:
BSB: 032-777
Account Number: 001922
Reference: [Insert Certificate of Authorisation Number]
	
PART D – 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 Certificate of Authorisation Number]	

Details of Licensee 	
Name of Licensee		Licence No. 		
Name of Venue		Certificate No. 		

PART A - Gross Gaming Machine Revenue (GGMR)	Month		
Turnover $	Total wins $	Metered Jackpots Paid $	Shortpays $	Unmetered Link J’pots Paid $	Multi-user Link Ctn $	Total Payouts B+C+D+E+F	Sub-total Gross Revenue A-G $	
A	B	C	D	E	F	G	H	
								
Total Gross Monthly Gaming Machine Revenue		
Less (Forfeited unclaimed linked jackpots for the corresponding month in previous year – from Section D)		
			Total Gross Revenue		

Tax Payable	
Total Tax Liability @25.9% (Before adjustments)	$	
Adjustments (As per statements received from Commission)	$	
Total Tax Payable
BSB: 032-777 Account Number: 002220	$	

THIS SECTION FOR OFFICE USE ONLY

	

PART C - Problem Gambling Assistance Fund Levy	
Total Gross Revenue (from Part A, Column H of this form)	$	
Levy Liability @ 0.75% (before adjustment)	$	
Total Levy Liability for the Month	$	
Adjustments (as per statements received from Commission)	$	
Total Levy Payable (BSB: 032-777 Account Number: 001922)	$	

PART D – Unclaimed Prizes	
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)	$	

PART E	DECLARATION	

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

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

(Signature) _______________________________ (Position)_______________________ (Date) ________________