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NAFTM
Agency Survey
Charitable Gaming Regulatory Agency Use Only
Timeframe: CY or FY
(-ending month)
Year
Agency Participant
Agency Contact
Contact's Email (NAFTM use Only)
Address 1
Address2
State/Province
Phone#
Website
Types of Gambling
Gross Receipts
Prizes Paid
Adj Gr Receipts
Paper Bingo
Electronic Bingo
Paper Pulltabs
Electronic Pulltabs
Raffles
Other
Total
Admin/lic fees and taxes -
Expenses
Net Proceeds =
# Licensees
#Staff
Budget
Information Sent
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