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<br /> <br />MAY 2 1 2003 <br /> <br />'Dta{{i.Jit",{ 1.'15;- <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />T;~~ ~\d. ~ Cl..~ <br /> <br />Gambling Location: <br /> <br />~ <br />I fL-):{) :LJ ,.J <br />y/o~ <br /> <br />MonthlY ear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />~ul W 1lJ-u.;-;'--'G <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 (1 ) site) <br /> <br />~lSL <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (1 ) site) <br /> <br />4'1lL <br /> <br />~7..~ <br /> <br />C. <br /> <br />Line a - line b <br /> <br />Miscellaneous Deductions (for this site only) <br />1. Pulltab tax to distnbutor _I Y9S <br />2. Combined receipts tax for this site "2 l.-9D <br /> <br />3. Federal Taxes (per schedule C/D) <br /> <br />4. <br /> <br />State Gambling Tax (per line 11) <br /> <br />1.0 <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />s19 \ <br /><sr~ ) <br />< 'LSb) <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />E. <br /> <br />Line c - line d <br /> <br />40% <br /> <br /><IDS 'I <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />S~rure: ~ ~ <br /> <br /><5'1 <br /> <br />10% <br />