Free 29885.pdf - Indiana

MONTHLY REPORT OF VENDING INCOME
State Form 29885 (R2 / 6-94) / BVIS 0003 Approved by State Board of Accounts 1994

DIVISION OF DISABILITY AGING AND REHABILITATIVE SERVICES , BLIND AND VISUALLY IMPAIRED SERVICES The information on this form is CONFIDENTIAL per IAC 12-12-5-1.
T elephone number Date (month, day, year)

See instructions on back of form.
Name of vendor

Address (number and street, city, state, ZIP code) Location TO Site number

Reporting period : FROM

MACHINE NUMBER
SNACK

PRODUCT
CRACKERS CANDY PASTRIES CHIPS MINTS / GUM COOKIES

UNIT PRICE

UNITS SOLD

TOTAL GROSS SALES

LESS SALES TAX PAID

ADJUSTED GROSS SALES

COMMISSION RATE PER CONTRACT

AMOUNT DUE TO STATE OF IN

TOTALS
COLD DRINK CANNED POP JUICE

TOTALS
SNACK CRACKERS CANDY PASTRIES CHIPS MINTS / GUM COOKIES

TOTALS
HOT DRINK COFFEE CHOCOLATE

TOTALS
COLD DRINK CANNED POP COLD DRINK CANNED POP JUICE

TOTALS GRAND TOTALS

T be submitted with your remittance check on or before the 15th o day of each month. I hereby certify that this information is correct to the best of my knowledge.
Signature of contractor

MAKE CHECK PAYABLE TO FAMILY AND SOCIAL SERVICES ADMINISTRATION AND MAIL TO: FAMILY AND SOCIAL SERVICES ADMINISTRATION / DIVISION OF DISABILITY AGING AND REHABILITATIVE , SERVICES BLIND AND VISUALLY IMPAIRED SERVICES 402 West Washington Street, P Box 7083 .O. Indianapolis, IN 46207-7083

DISTRIBUTION: White - Blind and Visually Impaired Services; Canary - Fiscal; Pink - Vendor

INSTRUCTIONS
This reporting form must be completed accurately and submitted with each month's commission check on or before the 15th day of each month. Begin with the columns on the left and move to the right. Machine number: Each machine should have a number affixed to the exterior or frame of the machine. Enter the number of the machine on the line provided. Unit Price: Enter here the selling price of each item vended (snack machines will have several prices). Units Sold: Enter the number of units sold. Total Gross Sales: Multiply the number of units sold by the selling prices and enter amount. Less Sales Tax Paid: Enter the amount paid. Adjusted Gross Sales: Enter total of sales less sales tax. Commission Rate: Enter the percentage of commission as written on your contract. Amount Due: Enter the amount due which is the adjusted gross sales multiplied by the commission rate per your contract. In the bottom right hand corner you will find a line for the total amount due to Blind and Visually Impaired Services. Please note that a separate report must be submitted for each Rest Area (each side of the road). You may submit one check with two (2) reports. The signature on this report must be the same as the signature on the contract. Make checks payable to : Family and Social Services Administration / Division of Disability, Aging and Rehabilitative Services.