Annual Certified Physical Inventory and Cash Count Summary
CI
Print or
Type
Use this form to record the total dollar value of ending inventory and start bank for all sites.
Organization name
Federal ID number
Site name and permit number
Total dollar value of ending
inventory by site (from Form INV)
Inventory and Cash Count
Minnesota tax ID number
License number
Fiscal year end
Total start bank by site
(from Form CC, line 7)
Totals
Sign Here
I declare that the information provided is correct and complete to the best of my knowledge and belief.
Signature of CEO (required)
Print name
Date
Signature of gambling manager (required)
Print name
Date
Within 30 days after the end of the organization’s fiscal year, mail Form CI along with completed Forms CC and INV to:
Minnesota Revenue, Mail Station 3350, St. Paul, MN 55146-3350.
Phone: 651-297-1772. TTY: Call 711 for Minnesota Relay.
(Rev. 12/12)
Form CI Instructions
All organizations must annually
complete and submit Form CI
to summarize the inventory and
cash count of all sites after
physical inventories and cash
counts have been conducted.
An annual certified physical inventory and
cash count summary must be completed
and submitted to the Department of Revenue within 30 days after the organization’s
fiscal year end.
The annual certified physical inventory and
cash count summary must be completed
and signed by the chief executive officer
(CEO) and the gambling manager.
How to File
From the Forms INV and CC received from
each site, record the site name and permit
number, total cost of ending inventory and
total start bank by site and total the results.
Signatures
The CEO and the gambling manager must
sign Form CI.
Questions?
Website:www.revenue.state.mn.us
Email: [email protected]
Phone: 651-297-1772
weekdays 8 a.m. to 4:30 p.m.
(TTY: Call 711 for Minnesota Relay)
We’ll provide information in another format
upon request to persons with disabilities.
Reminders
Total Start Bank
The total start bank should reconcile
with Form G1, line 23, and Schedule F,
line 6, for the month for which the cash
was counted.
Dollar Value (Cost) of Ending
Inventory
The dollar value (cost) of ending inventory by site must equal the ending inventory on Schedule A for each site.