CC
Annual Certified Cash Count by Site
Federal ID Number
Minnesota Tax ID Number License Number
Use this form to record the start cash amount by site. Use a separate form for each site.
Organization Name Site Name and Permit Number
Were there pull-tab and/or tipboard games in play at month end?
Part 1 (Must be completed by two individuals not
involved with the gambling operation or by a CPA.)
Yes (complete Parts 1, 2 and 3)
A
B
Part
Number
C
Serial
Number
Fiscal Year End
No (complete Part 1 and Part 3)
Part 2
(To be completed by a member involved with gambling operation if there were games in play at month end.)
Pull-tabs and Tipboards
Mfg
ID
Date Taken
Pull-tabs and Tipboards
D
Cash
Counted
E
Start
Bank
F
Cash in
Hand (D – E)
G
Ideal Gross
Receipts
H
Value Unsold
Tickets
I
Gross Receipts
(G – H)
J
K
Value of
Prizes
Net Receipts
(I – J)
L
Cash Long/
Short (F – K)
Totals from page 2 of CC
Totals
Start Bank Reconciliation
Part 3 (May be completed by a member involved with gambling operation)
1 Total cash counted (column D total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Total net receipts (column K total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Subtotal (subtract line 2 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Add cash short or subtract cash long (column L total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Verified start bank for games in play (add lines 3 and 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Start bank for other forms of gambling (i.e., paddlewheel, raffle or bingo banks) and/or back-up banks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Total start bank by site (add lines 5 and 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
I declare that the information provided is correct and complete to the best of my knowledge and belief.
Signature of Individual or CPA who Completed Part I (required)
Print Name
Title
Date
Signature of Second Individual (required if not conducted by a CPA)
Print Name
Title
Date
Individuals or CPA who completed Part 1: Provide the completed and signed Form CC to the organization’s CEO or gambling manager.
CEO or gambling manager: Attach Form CC to Forms CI and INV and mail to Minnesota Revenue, Mail Station 3350, St. Paul, MN 55146-3350.
Phone: 651-297-1772.
(Rev. 12/15)
CC
Page 2
Annual Certified Cash Count for Games in Play by Site (continued)
Organization Name Site Name and Permit Number
Federal ID Number
Part 1 (Must be completed by two individuals not
Part 2
(To be completed by a member involved with gambling operation if there were games in play at month end.)
involved with the gambling operation or by a CPA.)
Minnesota Tax ID Number License Number
Pull-tabs and Tipboards
Pull-tabs and Tipboards
A
B
C
D
E
F
G
H
I
J
K
L
Mfg
ID
Part
Number
Serial
Number
Cash Counted
Start
Bank
Cash in
Hand (D – E)
Ideal Gross
Receipts
Value Unsold
Tickets
Gross Receipts
(G – H)
Value of
Prizes
Net Receipts
(I – J)
Cash Long/
Short (F – K)
Totals (also enter on page 1 of CC)
Form CC Instructions
All organizations must annually complete
and submit a separate Form CC for each
site to record the certified cash count by
site.
How to File
A certified cash count must be taken for each site on the last
day of the fiscal year at the close of business, or the first day
of the new fiscal year before the start of business.
All cash must be counted and entered in column D. If there
are games in play, also complete columns A, B and C.
The certified cash count must be completed by:
• two members, officers or employees of the organization not directly involved in the organization’s gambling
activities who have been appointed by the organization’s
board; or
• an independent certified public accountant (CPA).
The individuals who conduct the cash count must sign the
form to certify that the information is correct.
Submit the completed Form CC to the chief executive officer (CEO) or gambling manager as soon as possible after
the close of the organization’s fiscal year. The organization
has 30 days from its fiscal year end to submit to the Department of Revenue the necessary reporting forms, including
Form CC for each site.
Part 1
Part 1 must be completed by two individuals of the organization who are not directly involved with the gambling
activities or by an independent CPA.
Part 2 (for pull-tab and/or tipboard games in
play only)
Part 2 may be completed by a member of the organization
who is involved with the gambling operation. However, the
individual(s) who conducts the cash count must observe the
game audit.
Audit each game in play. It is not necessary to close the
game after being audited.
Note: If the total shortages exceed 0.3 percent, the discrepancies should be investigated.
Part 3
Part 3 may also be completed by a member of the organization who is directly involved with the gambling operation.
Once all games in play have been audited and the cash
counted, enter the totals into the Start bank reconciliation
section.
Note: Any available start bank for other forms of gambling
(e.g. paddlewheel, raffle, linked and non-linked bingo or
electronic pull-tab banks) and/or back-up banks should be
included on line 6 for an accurate start bank total by site.
Signatures
The two individuals or CPA who conducted the cash count
must sign the form certifying the information is correct.
The individual who completes Parts 2 and 3 does not need
to sign this form.
Questions?
Website:www.revenue.state.mn.us
Email: [email protected]
Phone: 651-297-1772
weekdays 8 a.m. to 4:30 p.m.
We’ll provide information in another format upon request
to persons with disabilities.