Fillable Gaming Machine Account Summary (Department of Internal Affairs New Zealand)

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Gaming Machine Account Summary (Department of Internal Affairs New Zealand)

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Gambling Act 2003
Gaming Machine Account Summary
Privacy Act 1993
The particulars in this form which relate to individuals are personal
information under the Privacy Act. This information is required so that
the Department of Internal Affairs (the Department) can consider the
society’s application under the Gambling Act 2003. The information
will be held by the Department and may also be disclosed to the
Police and other agencies, subject to the Criminal Records (Clean
Slate) Act 2004. Any person about whom information is collected has
the right of access to, and correction of, that information.
Ofce use only
Application Number:
Responsible Ofcer:
Licence Number:
GC6 (Post Venue Payments Transition Year*)
THIS FORM IS USED BY MULTI-VENUE CLUBS AND OTHER SOCIETIES TO RENEW THEIR CLASS 4
GAMBLING LICENCES.
Please complete this form and attach all required documentation, then return the application to the Department
of Internal Affairs. You will receive an invoice detailing the fees payable before your application can be
processed. For a schedule of Gambling Licensing and Compliance Fees please refer to our website at
www.dia.govt.nz. Keep a copy of your completed application for your records.
SOCIETY INFORMATION
How to contact us
Freephone 0800 257 887 (New Zealand only)
Phone: +64 4 495 7200 Fax: +64 4 494 0656
Email: gambling.compliance@dia.govt.nz
Website: www.dia.govt.nz/gambling
Please call our freephone number if you
need any assistance to complete this form
Name of society
Current operator’s
licence number
Page 1 of 17
PART A
Date stamp
Fax Website
Phone number
Freephone
number
Finance email
address
NZGM
January 2018
Category B Renewals
Society type
(please tick one only)
Company Registered New Zealand Racing Board
Incorporated Society
Charitable Trust Other (please specify)
*POST VENUE PAYMENTS TRANSITION YEAR is in relation to the Gambling (Venue Payments) Regulations
2016 (The Regulations) and this ‘Transition Year’ GMAS (GC6) should be used for reporting on any nancial
year that commences on or after 3 October 2016.
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 2 of 17
Note: The contact person is the person who will answer any questions we might have during the renewal
process. Please ensure that this person can be contacted at the phone numbers provided during working hours.
It is assumed that the contact person for clubs will be the person responsible for the day-to-day operation of the
gaming machines.
Business address
(suburb) (town/city)
(post code) (country)
Postal address
(if different from above)
(suburb) (town/city)
(post code) (country)
Preferred contact method
(please tick only one)
Business extension
Business mobile
Business email
Home phone
Personal mobile
Personal email
Fax
Business phone
CONTACT PERSON INFORMATION
Title
(please tick)
Family name
First name
Middle name(s)
Preferred name
Main occupation
Mr Mrs Ms Miss
Role in society
Other (please specify)
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 3 of 17
PART B
ACCOUNTANT INFORMATION
Title
(please tick)
Family name
First name
Middle name(s)
Preferred name
Main occupation
Mr Mrs Ms Miss
Chartered
accountant’s
company name
Preferred contact method
(please tick only one)
Business extension
Business mobile
Home phone
Personal mobile
Business email
Personal email
Fax
Business phone
Business address
(suburb) (town/city)
(post code) (country)
Postal address
(if different from above)
(suburb) (town/city)
(post code) (country)
Other (please specify)
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 4 of 17
AUDITOR INFORMATION
Title
(please tick)
Family name
First name
Middle name(s)
Preferred name
Main occupation
Mr Mrs Ms Miss
Auditor’s company
name
Preferred contact method
(please tick only one)
Business extension
Business mobile
Home phone
Personal mobile
Business email
Personal email
Fax
Business phone
Business address
(suburb) (town/city)
(post code) (country)
Postal address
(if different from above)
(suburb) (town/city)
(post code) (country)
Other (please specify)
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 5 of 17
PART C
GAMING MACHINE ACCOUNT SUMMARY
Please refer to the separate Guidance Notes document.
The Department requires you to supply:
• nancial statements for the most recent nancial year, (i.e. annual report), audited by a qualied auditor.
• agreed-upon procedures report on the forecast nancial information. This must be prepared by an
Independent Chartered Accountant with a Certicate of Public Practice.
• a copy of your published list of grants or authorised purposes payments.
• an explanation for any qualied audit reports completed by your auditor.
• a management letter from your auditor (letter that the auditor sends to the club’s governing body describing
any ndings that come out of the audit).
• a copy of any agreement the Society has entered into with a management company.
You are also required to complete this Gaming Machine Account Summary. The gures in the Gaming
Machine Account Summary should cover the same period as those of your annual report.
Please attach your annual report with this application, or advise why you cannot do this (for instance,
nancial statements not yet audited at the time of application).
Current year gures from
(i.e. year annual report covers)
to
If other than 12 months, please explain.
• In completing this form you must itemise income and expenses if provision has been made on the form for a
specic income or expense item.
• All amounts must be GST exclusive (except where otherwise indicated) and, where appropriate, accrual
amounts.
• Societies are required to maximise their return to the community, minimise costs and comply with the
requirement to return at least 40.00% (GST exclusive) of proceeds to authorised purposes.
• Clubs should use the gaming portion of their Statement of Financial Performance to complete the Income
and Costs section.
• The entire Club’s Statement of Financial Position can be used to complete the Financial Position section of
this form. Alternatively, Clubs may use a Statement of Financial Position relating to gaming only to complete
the Financial Position section.
• All societies are required to provide a forecast for the 12 months following on from the end of the current
nancial year.
Number of gaming machines held by the society at
balance date
Number of venues held by the society at balance
date
CURRENT YEAR FORECAST YEAR
dd/mm/yyyy
dd/mm/yyyy
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 6 of 17
INCOME Taken from the statement of nancial performance.
Proceeds (excluding interest) turnover, minus total
prizes (including jackpots)
Interest on gaming machine funds
Depreciation recovered from gaming equipment
sales
Other income from gaming machine operations
itemise on a separate sheet
Total non-gaming machine income
GROSS PROCEEDS
CURRENT YEAR
$
FORECAST YEAR
$
A
B=SUM OF ABOVE
Accounting fees
Advertising and publishing
Audit fees
Bad debts
Bank charges other than interest on loans
Computer costs
Conference costs
Consultancy fees
Conversion costs - gambling equipment
Depreciation - gambling equipment
Depreciation - other
CURRENT YEAR
$
FORECAST YEAR
$
COSTS
Taken from the statement of nancial performance - see the Guidance Notes document.
Electricity
$ 0.00
$ 0.00
$ 0.00
$ 0.00
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
CURRENT YEAR
$
FORECAST YEAR
$
Page 7 of 17
Entertainment
Finance/loan fees other than interest on loans
Freight and installation
Gaming machine audit fees
Gaming machine duty
Honoraria
Electronic Monitoring System costs non-capital
Insurance
Interest on loans - bank
Interest on loans - nance company
Legal fees
Loss on sale of assets
Manager’s costs other than salary, travel and
accommodation
Membership fees
Motor vehicle costs other than depreciation
Ofce costs
Other costs
Other costs - item 1
Other costs - item 2
Other costs - item 3
Management Services Provider costs
$ 0.00
$ 0.00
Item 1
Item 2
Item 3
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 8 of 17
CURRENT YEAR
$
FORECAST YEAR
$
Other costs - item 4
Other costs - item 5
Other costs - item 6
Other costs - item 7
Other costs - item 8
Other costs - item 9
Other costs - item 10
Problem Gambling Levy
Rent or lease payments for premises
Salaries and wages - direct
Salaries and wages - indirect
Security costs
Service and repair of gambling related equipment
Service and repair - other
Service contractors other than for service and repair
of equipment
Storage of gambling equipment
Subscriptions
Tax
Telecommunications expenses
Territorial authority consents
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
CURRENT YEAR
$
FORECAST YEAR
$
Training costs
Travel and accommodation
Trustees’ costs other than Honoraria
Write offs of gaming machines or other
assets held to reect a zero value
Licence fees - class 4 operator’s licence - new
licence
Licence fees - class 4 operator’s licence - renewal
of licence
Licence fees - class 4 operator’s licence - other
licence fees
Licence fees - class 4 venue licence -
new licence
Licence fees - class 4 venue licence -
renewal of licence
Licence fees - class 4 venue licence -
other licence fees
Licence fees - class 4 venue annual fee - annual fee
per gaming machine
TOTAL OPERATOR COSTS
C
TOTAL VENUE PAYMENTS
TOTAL COSTS
NET PROCEEDS total proceeds minus
total costs
CURRENT YEAR
$
FORECAST YEAR
$
VENUE COSTS
Page 9 of 17
E=C+D
D
F=B-E
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 10 of 17
CURRENT ASSETS
Accounts receivable - general
Accounts receivable - proceeds not banked
Cash at bank
GST receivable
Investments term deposits
Petty cash
Prepayments
Other current assets
CURRENT YEAR
$
FORECAST YEAR
$
FINANCIAL POSITION Taken from the statement of nancial position.
TOTAL CURRENT ASSETS
G
NON-CURRENT ASSETS
Investments
Property, plant and equipment
Other non-current assets
CURRENT YEAR
$
FORECAST YEAR
$
TOTAL NON-CURRENT ASSETS
H
$ 0.00
$ 0.00
$ 0.00
$ 0.00
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 11 of 17
CURRENT LIABILITIES
Bank overdraft
Current portion - term loans
Distributions approved but remaining to be paid
CURRENT YEAR
$
FORECAST YEAR
$
TOTAL CURRENT LIABILITIES
Employee entitlements
Gaming duty provision
GST payable
Other current liabilities
Payables and accruals
Tax payable
Unclaimed prizes
I
NON-CURRENT LIABILITIES
Term loans - hire purchase
Term loans - bank
Term loans - nance company
CURRENT YEAR
$
FORECAST YEAR
$
TOTAL NON-CURRENT LIABILITIES
Other non-current liabilities
J
CURRENT YEAR
$
FORECAST YEAR
$
WORKING CAPITAL
G-I
NET ASSETS
K=(G+H)-(I+J)
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 12 of 17
Undistributed funds at the beginning of the year
opening equity
PLUS
Undistributed surplus/decit prior to
distributions net proceeds
PLUS Distributions made, then returned to society
from the previous period
EQUALS Net proceeds available for distribution
LESS
Distributions made during the nancial year
EQUALS UNDISTRIBUTED FUNDS AT THE END
OF THE YEAR closing equity
CURRENT YEAR
$
FORECAST YEAR
$
UNDISTRIBUTED FUNDS Taken from the statement of movements in equity and the notes - gaming only.
F
M
FINANCIAL POSITION NETS TO ZERO
net assets (liabilities plus equity)
CURRENT YEAR
$
FORECAST YEAR
$
N=K-M
L
OPERATING CASH FLOWS
Gaming machine receipts
Other operating receipts
Authorised purpose distributions
Other operating payments
NET OPERATING CASH FLOWS
CURRENT YEAR
$
FORECAST YEAR
$
CASH FLOW Taken from the statement of cash ows.
O
INVESTING CASH FLOWS
Sale of non-current assets
Other investing receipts
Purchase of non-current assets
Other investing payments
NET INVESTING CASH FLOWS
CURRENT YEAR
$
FORECAST YEAR
$
P
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 13 of 17
FINANCING CASH FLOWS
Cash from nancing activities
Cash applied to nancing activities
NET FINANCING ACTIVITIES CASH FLOWS
CURRENT YEAR
$
FORECAST YEAR
$
Q
NET INCREASE/DECREASE
IN CASH HELD
Opening cash balance
Closing cash balance
CURRENT YEAR
$
FORECAST YEAR
$
R=O+P+Q
Net proceeds available for distribution
LESS Undistributed funds available to be carried
forward to next year
EQUALS Funds distributed this year excluding
GST- cash paid out must match published list of
grants/authorised purposes, where GST has not been
paid
PLUS GST on grants where GST has been paid
EQUALS Funds distributed this year including GST
must match published list of grants where GST has
been paid
CURRENT YEAR
$
FORECAST YEAR
$
DISTRIBUTION TO AUTHORISED PURPOSES
L
S
M
PERCENTAGE OF TOTAL PROCEEDS DISTRIBUTED
Total proceeds excluding GST
Funds distributed this year excluding GST cash
paid out
Percentage of total proceeds
distributed in current nancial year
CURRENT YEAR
$
FORECAST YEAR
$
B
S
T=S/Bx100
Please attach an agreed-upon procedures report on the forecast nancial information. This must
be prepared by an Independent Chartered Accountant with a Certicate of Public Practice.
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
0.00%
0.00%
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
PART D
RENEWAL OF PREVIOUS APPROVAL TO ACCUMULATE FUNDS
A corporate society that does not mainly distribute proceeds from class 4 gambling to the community, and had
approval to accumulate funds last year for a specic project, may apply to have that approval renewed for a
further year.
Note: This is solely for renewal of a previous approval. If you wish to accumulate funds for a specic project and
did not receive approval to do so during the last licensing year, then you cannot apply here. Instead, you must
complete the relevant section in the GC2A application form and pay the relevant application fee.
1 Date of letter giving original approval:
2 Details of what the project involves:
3 Cost of project:
4 Amount accumulated to date:
5 Details of what stage the project is currently at:
6 Date by which accumulation of funds is expected to be complete:
7 Any further information you wish to provide on your accumulation or project (optional):
Page 14 of 17
Please answer all of the following questions concerning the requested renewal of your approval:
$
$
dd/mm/yyyy
dd/mm/yyyy
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
Page 15 of 17
CERTIFICATION
To be completed by the Chair of Trustees or President and Chief Executive Ofcer or General Manager.
dd
dd
mm
mm
yyyy
yyyy
We certify that we are authorised to make this certication on behalf of the applicant society.
All the details entered in and provided with this GC6 Category B Class 4 Operator's Licence
Renewal Application are true and correct to the best of our knowledge.
We understand that if false or misleading information has been provided in this application, any
licence issued to the society pursuant to the Gambling Act 2003 may be cancelled, suspended or
amended.
We have understood the relevant regulatory requirements. If needed, we have obtained or will
obtain legal advice to ensure compliance with these requirements.
Trustee's or ofcer's
last name
All rst name(s)
Position in society
Signature
Date
Trustee's or ofcer's
last name
All rst name(s)
Position in society
Signature
Date
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
CHECKLIST
If you are applying to renew your class 4 operator’s & venue licence(s) you need to send the
following to the Department of Internal Affairs:
Completed Gaming Machine Account Summary
Financial statements for the most recent nancial year (i.e. annual report), audited by a
qualied auditor
An agreed-upon procedures report on the forecast nancial information. This must be
prepared by an Independent Chartered Accountant with a Certicate of Public Practice
(please tick)
A copy of your published list of grants or authorised purposes payments
Statement of how you intend to minimise expenses and maximise returns to the
community
An explanation for any qualied audit reports completed by your auditor
Management letter from your auditor (letter from the auditor sent to the board describing
any ndings that came out of the Audit) and audit report
You may be required to provide further information to assist the Department in assessing your
application.
If your application is incomplete or missing supporting documentation, it will be returned to you without
being processed. Please also check the accuracy of the application and supporting information as
inaccuracies/inconsistencies will cause signicant delays.
Page 16 of 17
A copy of any agreement the society has with a management company
A list of your venues, sorted by venue name, and showing licence number, current venue
operator, current venue manager and total amount of venue payments made to the venue
operator for the reporting period – see example below. Please ensure that an electronic
spreadsheet can be provided on request
Venue Name GMV Current Venue Operator Current Venue Manager Actual Annual Venue Payment
Jane’s Club 201 Jane Doe Jane Doe $0.00
Pub Doe 200 JD Ltd John Doe $0.00
Smith’s Tavern 199 Smith Ltd John Smith $0.00
January 2018
Category B Renewals Gaming Machine Account Summary (GC6) Post Transition
How to contact us
Freephone 0800 257 887 (New Zealand only)
Phone: +64 4 495 7200 Fax: +64 4 494 0656
Email: gambling.compliance@dia.govt.nz
Website: www.dia.govt.nz/gambling
Please call our freephone number if you
need any assistance to complete this form
Page 17 of 17
RETURN COMPLETED APPLICATION TO:
By email:
Gambling.Licensing@dia.govt.nz
By post:
Licensing Compliance
Department of Internal Affairs
PO Box 10-095
Wellington 6143
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Completed 29 June 2022

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