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<br /> <br />'EstaGfisfietf .1857 <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />Organization Name: <br /> <br />~O""'....q La 1L"t! & Y"Ii( L ,'61;1 S <br />I J <br />I~ I & ~ ~,,~ \A'" v <br />.-1:J d R~C h ~-3 <br /> <br />Gambling Location: <br /> <br />MonthlYear: <br /> <br />Name of Individual Completing Form: <br /> <br />LJ~ah C II~ y <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A. <br /> <br />Net Receipts - Total lines 2c, 3c, 8c, 9c <br />(per Schedule A if more than one (I) site) <br /> <br />If jt')3 ~~.CO <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (1 ) site) <br /> <br />!5/~ /, eJQ <br /> <br />C. <br /> <br />Line a - line b <br /> <br />:1/10 I. acJ <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />1. Pulltab tax to distributor y 7 tj 7. CtJ <br />/../ "3 q :;; CJ X . (!) / 7 -= rl7 '17 . ~" <br />2. Combined receipts tax for this site tf( .;s:3 q. 00 <br /> <br />-;zglo 1.[5 x . o7'F ==112211./,00 <br />3. Federal Taxes (per schedule C/D) <br /> <br />4. State Gambling Tax (per line 11) <br />1"3(.; 7- ^ ,fiRS --;..(f II~ .00 <br />D. Total Miscellaneous Deductions for this site <br /> <br />II b. 00 <br /> <br />30'17.00 <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />< q 3m> <br /><'I~~> <br /> <br />E. <br /> <br />Line c - line d <br /> <br />40% <IF?, '7 <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />10% < '-1-7) <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: <br /> <br />;/ . <br />d~ /Cf~ <br />