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<br />" <br /> <br />MINNESOTA * REVENUE G-1 <br /> <br />Lawful Gambling Monthly Summary and Tax Return <br /> <br />n Organization Name Organization License Number <br />SPRING LAKE PARK LIONS CLUB 00584 <br /> <br />Street (Address) <br />8433 CENTER DR. <br /> <br /><1>) <br />c..1 <br />>0' <br />1-: <br />....' <br />0: <br />~I <br />0-1 <br />, <br />I <br />L-J <br /> <br />City <br />SPRING LAKE <br /> <br />Month and year reported <br />4 I 2003 <br /> <br />State <br />MN <br /> <br />Zip Code <br /> <br />55432 <br /> <br />:J Amended return <br />;--; <br />U No gambling activity this mO"1th <br /> <br />Number of premises <br />6 <br /> <br />o Filling extension (attach letter) <br />Ci Final return (attach approval letter) <br /> <br />Number of pulltab and paddle ticket games <br />reported on Schedule 8-2s for the month: 934 <br />This return indudes (check): <br /> <br />Check all <br /> <br />that apply: <br /> <br />U Schedule A (# of Pages <br /> <br />6 ) <br /> <br />U Schedule 8.2 (# of Pages 67) <br /> <br />0.00 <br /> <br /> o Schedule F <br /> Column C <br /> net receipts <br /> 0.00 <br /> 669.00 <br /> 50901.00 <br /> 51570.00 <br /> 0.00 <br /> 51570.00 <br /> 0.00 <br /> 0.00 <br /> 102285.00 <br /> 153855.00 <br />11 4383.45 <br />12 26704.47 <br />13 31087.92 <br /> <br /> Column A <br /> gross receipts <br /> 1 Bingo 1 0.00 <br /> 2 Raffles (if tax-exempt raffles were conducted, <br /> check here 0 and complete Schedule ER) 2 669.00 <br /> 3 Paddletickets 3 400890.00 <br /> 4 Add lines 1 through 3 4 401559.00 <br />.... 5 If line 6C of last month's G1 is negative, enter the <br />~ <br />0 amount without parentheses in columns A and C 5 0.00 <br />.... <br />0- <br />III <br />III 6 Subtract line 5 from line 4 6 401559.00 <br />0 <br />.... <br />C) 7 Income from interest and dividends (enter <br /> the same amount in columns A and C) 7 0.00 <br /> 8 Tipboards 8 0.00 <br /> 9 Pulltabs 9 523617.00 <br /> 10 Add lines 6 through 9. Line 10C is your <br /> gross profits for the month 10 925176.00 <br />n 11 Multiply line 6C by 8.5% (.085) <br /> (if line 6C is a negative number, enter zero) (effective 7-1-00) <br />>< <br />lU 12 Combined-receipts tax, if any (from line 9 of Schedule E) <br />I- <br /> <br />Column B <br />prizes <br /> <br />0.00 <br /> <br />349989.00 <br /> <br />349989.00 <br /> <br />349989.00 <br /> <br />0.00 <br /> <br />421332.00 <br /> <br />771321.00 <br /> <br />13 Add lines 11 and 12 and PAY TH!S ..l\MOUNT. Make check payable to Minnesota Revenue <br />(if exempt raffles were reported, pay amount on Schedule ER, line 6, instead) <br /> <br />U <br />-l <br />III <br />Ql <br />>< <br />lU <br />J- <br /> <br />14 TotaI1.? percent tax paid during the month, if any (listed on distributors' invoices <br />for pu/ltabs and tip boards ) <br /> <br />14 ______~~57.64_h_ <br /> <br />.... . 15 Add lines 13 and 14 <br />Ql <br />~ <br /> <br />15 40645.56 <br /> <br />16 Gross profits after state taxes (subtract line 15 from line 10C) <br />Enter the result here and on line 17 on the back of this form. <br /> <br />16 113209.44 <br /> <br />Ql <br />.... <br />Ql <br />X <br />C <br />.~ <br />rn <br /> <br /> <br />Date Dayti~lfg <br />4tjJ(J~ 1'it/ 7/7' <br />DalE( . Daytime Pho;;; <br />