FORM NO. 233 as REVISED FEB 00 P.O. Box 1795 Concord NH 03302-1795 State of New Hampshire STATE LIQUOR COMMISSION FINANCIAL STATEMENT OF CLUB OPERATIONS NAME OF CLUB Address Statement for Month Ending City or Town Membership to Date 20 License No. STATEMENT OF PROFIT AND LOSS INCOME FOR MONTH Sale of Liquor Sale of Beer Dues Miscellaneous (Itemize in space (e) below) (a) Total Income OPERATING EXPENSES Rent (Indicate to whom paid in space (d) below) Salaries (Itemize in space (f) below) $ Heat, Light, Water, Telephone Insurance and Interest Repairs and Alterations Janitorial Services & Supplies Taxes Donations Licenses Transportation Socials & Benefits Entertainment Loss and Waste Contract Service Expense $ COSTS OF GOODS SOLD Inventory Beginning: $ Liquor Beer Bar Supplies Miscellaneous Total Add – Purchases: $ Liquor Beer Bar Supplies Miscellaneous Total Merchandise Available Deduct – Inventory Ending: Liquor Beer Bar Supplies Miscellaneous Total Merchandise Available (b) Costs of Goods Sold $ $ $ (c) Total Expenses $ PROFIT AND LOSS (a) Total Income (b) Less – Costs of Goods Sold Gross Profit (or Loss) (c) Less – Operating Expenses Net Profit (or Loss) $ $ $ Rent (To Whom Paid) (d) Name Amount Salaries (f) $ $ Name Amount $ $ Miscellaneous Income (e) Itemize Sundries – Food Socials Etc. Commissions $ $ $ $ $ $ $ $ $ Amount $ $ $ $ BALANCE SHEET ASSETS Checking Account Savings Account Cash on Hand Petty Cash or Change Fund Merchandize Inventory Bonds Real Estate Furniture and Equipment Total Assets First of Month $ $ $ $ $ $ $ $ $ Last of Month $ $ $ $ $ $ $ $ $ LIABILITIES & SURPLUS Accounts Payable Notes Payable Mortgage Payable Taxes Payable Surplus Total Liabilities & Surplus First of Month $ $ $ $ $ $ Last of Month $ $ $ $ $ $ Note: Assets for each month should balance with Liabilities and Surplus – CERTIFICATION TO THE COMMISSIONERS – I/We certify and affirm declare that all answers herein above contained are true and correct to the best of my/our knowledge and belief and understand that this statement is made subject to the penalties of unsworn falsification described in RSA 641:3. (Date) (Officers Signature) (Expiration Date) (Officers Signature) (Date) (Title) (Title) (Expiration Date) This Statement shall be forwarded to the Commission prior to the fifteenth (15) day of the following month. Subject to administrative action if late. – COMMISSION USE – (Date Received: Late: Days) (Analyzed by: Date: ) (Audited by: Date: ) – REMARKS – American LegalNet, Inc. www.FormsWorkflow.com