Free Form AU-215 - New York

New York Department of Taxation and Finance

Pari-Mutuel Tax Return of Uncashed Pari-mutuel Tickets
Under Sections 232, 328, 426, and 529 of the Racing Pari-Mutuel Wagering and Breeding Law
Association name

AU-215
(8/04)
Federal employer identification number (EIN)

Number and street

City, State, ZIP code

Racing season

Part 1 (to be completed and filed by March 15th) 1 Total amount of uncashed tickets as of December 31 ............................................................................ 2 Uncashed ticket balance as of last day of February ................................ 2. 3. 1.

3 Balance of uncashed tickets to be remitted (multiply line 2 by .95) .......................................................... Part 2 (to be completed and filed by April 10th) 4 Uncashed ticket balance as of March 31st ...................................... 5 Other unclaimed funds .................................................................... Identify: 6 Total liability (add lines 4 and 5) ................................................................................................................ 7 Amount previously remitted (from line 3 above) ....................................................................................... 8 Balance of amount of uncashed tickets to be remitted (subtract line 7 from line 6) ...................................
Signature of authorized person Title

4. 5.

6. 7. 8.
Date

Signature of individual or name of firm preparing this return

Preparer's address

State of New York County of I, , being duly sworn, deposes and says that he is the of the , a corporation or association duly authorized to conduct pari-mutuel betting under Chapter 865 of the laws of 1982, and that the foregoing report, made pursuant to sections 232, 328, 426 and 529 of said chapter, contains a true and accurate statement of the total of all sums of unpaid money due on account of pari-mutuel tickets not presented for the year for which this return is made. Sworn to before me this day of

Notary Public

Make your check or money order payable to: Commissioner of Taxation and Finance. Mail this original return to: New York State Department of Taxation and Finance, PO Box 5048, Albany NY 12205-0048 Also send a copy of this return with a copy of the uncashed ticket report verifying the indicated balance to: New York State Tax Office, Pari-Mutuel Revenue, PO Box 90, Jamaica NY 11417