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ENTERTAINMENT FACILITIES2012 Report Form for Calendar TrimesterAccount Number:Premise Name:Jan-Apr May-Aug Sep-Dec Report Type (Please select one):(Please Select one Trimester per report) Estimate ActualNAME OF PARK: ______________________________ SEASON PERIOD: FROM: ______________ TO: ______________A. COMPUTATION OF FEE:I. NUMBER OF DAYS MECHANICAL MUSIC IS USED THROUGHOUTTHE PARK DURING THE YEAR - Number of Days x $4.30 $_______________II. FEE FORA. Audio Uses - Number of Speakers ______($225.50 up to 3 speakers $46.50 Each Additional SpeakerMaximum Year’s License Fee $1,890.50) Fee: II A $_______________B. Audio Visual Uses – Number of Speakers($339.50 up to 3 speakers $69.00 Each Additional SpeakerMaximum Year’s License Fee $2,853.50) Fee: II B $_______________III. SUBTOTAL - ANNUAL FEE FOR MECHANICAL MUSIC(Line I. + Line II. A. + B.) = $___________________IV. TRIMESTER FEE FOR MECHANICAL MUSIC IS 1/3 THE ANNUAL FEE $B. LIVE MUSIC ENTERTAINMENT EXPENSES (COSTS)1. Please attach this Trimester’s Event Report at which Live Music Entertainment occurred $___________________***********************************************************************Total Trimester's License Fees (Line A. IV + Line B. I.): $___________________Contact Person & TitlePhone Number: - - Ext: Fax Number: - -Email:I certify the above information is true and correct.Dated:/ /Signature:Website:ASCAP, PO Box 331608-7515, Nashville, TN 37203-9998 1-800-505-4052 615-691-7795 (FAX)Epayment Websites: http://www.ascap.com/mylicense or http://www.ascap.com