Reportisforusebypromoters to Reportgross Receipttaxesdue. Taxes Reportduewithin FIVE(5)BUSINESS

ArkansasStateAthleticCommission

Arkansas Department of Health/Combative Sports
4815 W. Markham St. Slot 36 Little Rock, AR 72205 PHONE(501)687-1038 FAX(501)255-0394
Email Address: Internet Address:

GrossReceiptsTaxReport

•ReportisforusebyPromoters to reportGross ReceiptTaxesDue. Taxes ReportduewithinFIVE(5)BUSINESS DAYS after eachEvent.

•ReadandcomplywithCommission RegulationswhensubmittingthisReport.

•Taxcomputedas5%ofGROSSGATERECEIPTSunlessvenue collectsremitssalestaxesonallgatereceiptsforPromoter,inwhichcasetaxiscomputedas5% ofNETGATERECEIPTSaftersalestaxes. PromoterisresponsibleforcomplyingwithallDepartmentofFinanceandAdministrationregulationsandArkansas statutesregarding remittance of salestaxes,whichareseparatefromtheCommission’sGross ReceiptsTax authorizedandrequired byArk. CodeAnn.§ 17-22-306.

•Commissionmayrequiresubmissionof “DeadWood”and/or TicketManifests andother reports to validateand auditthisReport.

DidVenue CollectRemitSales Taxeson Gate Receipts?
YesNo
If Yes,anVenueRepresentativeMust SignCertification StatementOnThisReport. / Were Tickets SoldUsinga ComputerizedSystem:
YesNo
If Yes,Ihaveattachedatruecorrectsystem reportwithallticketsales &prices.
GeneralAdmission:
NumberAvailable: PricePerTicket: $_
Number Sold: Gen.Adm.Receipts $ / ReservedSeating(Price Tier 1):
NumberAvailable: _PricePerTicket: $
Number Sold: Price Tier1Receipts$
ReservedSeating(Price Tier 2):
NumberAvailable: PricePerTicket: $_
Number Sold: Price Tier2Receipts$ / ReservedSeating(Price Tier 3):
NumberAvailable: _PricePerTicket: $
Number Sold: Price Tier3Receipts$
Complimentary/Promotional/Give-AwaySeating(Price Tier4):
(See CommissionRegulation1.15.3.8)
NumberAvailable: _PricePerTicket:$ _
NumberDistributed: Price Tier4Tax$ _ / InspectorFee: ______
MMADatabaseUpload Fee: ______Lic:______
Gate Receipts Total:
TOTAL Remittance:
RESERVED FOR COMMISSION USE
$ReceivedonDayof20
MethodofPayment:Cashier’s CheckCash
MoneyOrderCompanyCheckCreditCard
Funds Deposited Dayof 20_ CommissionRepresentative: / TotalGrossReceipts TaxDue:
TotalReceipts: GeneralAdmission: $ Price Tier1 $ Price Tier2 $ Price Tier3 $ Price Tier4 $
TotalReceipts$
TotalReceipts Multiplied By5%Equals $DUE

Bysignaturebelowandunderpenaltyofperjury,Iswearoraffirm: 1.)IamthePromoterorAuthorizedRepresentativeforPromoter;2.) Promoter compliedwith allapplicable CommissionRegulationsfor this Event;and3.)The foregoinginformationis trueandaccurate.

Promoter’s Name: Telephone #: Fax#:

EventDate: EventPermit #EventVenue/Address:

Signed:

_

AuthorizedPromoter’s RepresentativePrintedNameTitle

_ Date:

***IFSALES TAXESWERECOLLECTEDBY VENUEOPERATOR, THENVENUEOPERATORMUSTSIGN* * *

IherebycertifyunderpenaltyofperjurythatIamanauthorizedrepresentativeoftheVenuefor theabovedescribedEventandallapplicable sales taxesintheamountof$ werewithheldonallticketsalesasreportedhereinthesamewereremittedtotheStateofArkansasonthe

dayof _20basedonticketsales of$_andNetTicket Sales After Sales Taxare $_.

AuthorizedVenueRepresentative_PrintedName_Title_Date