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<br /> <br />'E.-tatifi..;/irtf lS5;- <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />l)~ ~ ~vl G-vE> <br />lr-T~~ 6:v,,\S ~1:'1:1. A <br />q/o:!:' , <br /> <br />Organization Name: <br /> <br />Gambling Location: <br /> <br />MonthlY ear: <br /> <br />~0l W \2v~~ <br /> <br />Name oflndividuaI Completing Fonn: <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A. <br /> <br />B. <br /> <br />C. <br /> <br />Net Receipts - Total lines 2c, 3c, 8c, 9c <br />(per Schedule A if more than one (I) site) <br /> <br />Z'1<61.o <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (I ) site) <br /> <br />"3S45 <br /> <br />Line a - line b <br /> <br /><~'> <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />D. <br /> <br />E. <br /> <br />F. <br /> <br />Signature: <br /> <br />1. <br /> <br />loq 1- <br />--'I~ <br /> <br />Pulltab tax to distnbutor <br /> <br />2. <br /> <br />Combined receipts tax for this site <br /> <br />3. Federal Taxes (per schedule C/D) <br /> <br />4. <br /> <br />7- <br /> <br />State Gambling Tax (per line 11) <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />1401 <br />< 20 n..} <br /><\OO~) <br /> <br />Line c - line d <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />40% <br /> <br />< 1;D~~ <br />< 'VO 7..-') <br /> <br />List Receivers offundslor attach a <br />separate page <br /> <br />10% <br /> <br />PAYABLE TO THE CITY OF <br />CENTERV~LE*DUEANNUALLY <br />AS PER ORDINANCE* <br /> <br />~w~ <br />