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

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March 2017
Category A Club Renewals
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:
GC7
THIS FORM IS FOR SINGLE VENUE CLUBS THAT OPERATE ON THEIR OWN PREMISE ONLY. MULTI
VENUE CLUBS AND CLASS 4 OPERATOR LICENCE HOLDERS THAT ARE NOT CLUBS MUST
COMPLETE THE GC6 CATEGORY B GAMING MACHINE ACCOUNT SUMMARY FORM.
Please complete this form and attach all required information, 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.
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 1 of 12
Date stamp
SOCIETY INFORMATION
Name of society
Current operator’s
licence number
PART A
Fax Website
Phone number
Freephone
number
Finance email
address
NZGM
Society type
(please tick one only)
Company Registered New Zealand Racing Board
Incorporated Society
Charitable Trust Other (please specify)
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
Page 2 of 12
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)
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
Page 3 of 12
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)
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
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)
Page 4 of 12
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
Page 5 of 12
PART C
GAMING MACHINE ACCOUNT SUMMARY
Please refer to the separate Guidance Notes document.
The Department requires you to:
• complete the Gaming Machine Account Summary (GMAS) on pages 5-7 and have an Independent Chartered
Accountant with a Certicate in Public Practice complete PART D.
• provide 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).
The current year gures in the GMAS 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).
• In completing this form you must itemise income and expenses wherever provision has been made on the form
for those specic income or expense items.
•
All amounts must be GST exclusive (except where otherwise indicated) and, where appropriate, accrual
amounts.
•
Clubs are required to maximise their return to the community, minimise costs and comply with licence condition
1, concerning the application and/or distribution of proceeds to authorised purposes.
•
Clubs should use the gaming portion of their Statement of Financial Performance to complete the Income and
Costs section.
•
Clubs 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
GAMING INCOME taken from the statement of nancial performance
Proceeds (exluding 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
A
$
CURRENT YEAR FORECAST YEAR
$
Current year gures from
(i.e. year annual report covers)
to
If other than 12 months, please explain.
dd/mm/yyyy
The amounts entered into Gaming Machine Account Summary form must match the Club’s audited nancial
Statement of Accounts. When these do not agree in every detail, it is not possible for the Secretary to
conclude as to the nancial viability of the “proposed gambling operation” as set out in this form.
!
dd/mm/yyyy
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
Page 6 of 12
$$
GROSS PROCEEDS
B= SUM OF ABOVE
CURRENT YEAR FORECAST YEAR
Accounting fees gaming operations only
Audit fees gaming operations only
GAMING COSTS Taken from the statement of nancial performance. See the Guidance Notes document.
Depreciation - gambling equipment
Electronic Monitoring System (EMS) costs non-capital
Gaming machine duty
CURRENT YEAR
$
FORECAST YEAR
$
Interest on loans - bank
Interest on loans - nance company
Loss on sale of gaming assets including write-offs
Other costs break down on a separate sheet required if
total is more than $5,000
Insurance
Problem Gambling Levy
Salaries and wages relating to gaming operation
Service and repair of gaming machines
Training costs
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
Electricity
Licence fees - class 4 venue licence - renewal of
licence
Management Services Provider costs
$ 0.00
$ 0.00
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
Page 7 of 12
CURRENT YEAR
$
FORECAST YEAR
$
Licence fees - class 4 venue annual fee - annual
fee per gaming machine
TOTAL COSTS OF GAMING OPERATION
C
Net proceeds from gaming operations
Undistributed funds carried forward from last year
FUNDS AVAILABLE TO BE DISTRIBUTED
OR APPLIED FOR AUTHORISED
PURPOSES THIS YEAR
Please read the Guidance Notes for calculating Authorised Purpose payments before completing this
section.
Authorised Purpose payments (excluding
GST)
Percentage of gross proceeds distributed
or applied
D=B-C
E
F=D+E
G
G/Bx100
Licence fees - class 4 venue licence - other licence
fees
Undistributed funds available to carry
forward to next year
H=F-G
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
0.00%
0.00%
$ 0.00
$ 0.00
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
Page 8 of 12
PART D
GUIDANCE - Agreed Upon Procedures on Forecast Financial Information
The Gambling Act 2003 requires the Department to assess the nancial viability of the Club’s proposed
gambling operations.
The Department requires an Independent Chartered Accountant with a Certificate of Public Practice to verify
the financial information provided in the Gaming Machine Account Summary form by performing the
procedures set out below. This engagement needs to be carried in accordance with the New Zealand Institute
of Chartered Accountants Engagement Standard APS-1 (Revised) Agreed-Upon Procedures Engagement to
Report Factual Findings.
Relevant terms in this guidance
Forecast year means the financial year immediately after the current financial year
Current year means the most recent full financial year
PROCEDURES
1. Obtain “Part C of the Gaming Machine Account Summary form” and the underlying assumptions prepared
by the entity;
2. Compare the “current year” gures to the audited nancial statement of the same period;
3. Check the “forecast year” gures have been approved by the entity’s governing body;
4. Compare the accounting policies and management estimates used for the “forecast year” gures were the
same as used in the audited nancial statements for the preceding period to te forecast year;
5. Compare the “forecast year” gures to the assumptions set out by the entity;
6. Re-perform the calculations for the “current year” gures and the “forecast year” gures.
An example of a report can be found on the Department’s website.
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
Page 9 of 12
PART E
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 to amend class 4 operator’s licence 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):
Please answer all of the following questions concerning the requested renewal of your approval:
dd/mm/yyyy
dd/mm/yyyy
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
Page 10 of 12
Trustee’s or ofcer’s
last name
All rst name(s)
Position in society
Signature
Date
CERTIFICATION
To be completed by the Chair of Trustees or President and Chief Executive Ofcer or General Manager.
Trustee’s or ofcer’s
last name
All rst name(s)
Position in society
Signature
Date
dd mm yyyy
dd mm yyyy
We certify that we are authorised to make this certication on behalf of the applicant society.
All the details in and provided with this 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
appplication, any license issued to the society pursuant to the Gambling Act 2003 may be
cancelled, suspended or amended.
We have understoof the relevant regulatory requirements. If needed, we have obtained or
will obtain legal advice to ensure compliance with these requirements.
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
CHECKLIST
All items on this checklist MUST be provided are applying to renew your Class 4 Operator’s and Venue
Licence(s) you need to send the following to the Department of Internal Affairs:
completed Gaming Machine Account Summary (PART C)
nancial 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.
a copy of your published list of grants or authorised purposes payments
an explanation for any qualied audit reports completed by your auditor
statement on how the club is minimising expenses and maximising returns to authorised
purposes
a copy of any agreement the society has with a management company
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) 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 11 of 12
March 2017
Category A Club Renewals Gaming Machine Account Summary (GC7)
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 12 of 12
Licensing Compliance
Department of Internal Affairs
PO Box 10-095
Wellington 6143
BY POST:
Return the completed and signed application and all attachments to EITHER:
BY EMAIL:
Gambling.Licensing@dia.govt.nz
* PLEASE NOTE: that while the Department of Internal Affairs will take all reasonable steps to reduce the risk of unauthorised access or
release of confidential information, it can't guarantee that your emails won’t be intercepted or read while in transit. Please also ensure that you
use the correct email address when sending your application.
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