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<br />License Number <br />03800 <br />MonthlY ear reported <br />A ril 2003 <br />Number of Sites <br />5 <br />[ ] Filing extenision request <br />this month [] Final return <br /> <br />MINNESOTA REVENUE <br />LAWFUL GAMBLING MONTHLY SUMMARY and TAX RETURN <br /> <br />Organization Name <br />Dead Broke Saddle Club <br />Address <br />19680 Harrow Ave N. <br />City <br />Forest Lake <br />Number of games reported <br />on Schedule B2s: 274 <br />This return includes <br />[x] Schedule A (5 pages) <br /> <br /> <br />State <br /> <br />[x] Schedule B2 (22 pages) <br /> <br />(A) Gross receipts <br /> <br />0.00 <br /> <br />[xl Schedule F <br /> <br />(B) <br /> <br />Prizes <br /> <br />1 Bingo. . . . . . . . . . . . . . . . . . . . . . . . . 1 <br /> <br />0.00 <br /> <br />2 Raffles [ ] check if tax exempt. attach Schedule-ER. . 2 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />3 Paddletickets . . . . . . . . . . . . . . . . . . . . . 3 <br /> <br />5340.00 <br /> <br />5162.00 <br /> <br />4 Sub-Total (add lines 1 through 3). . . . . . . . . . . 4 <br /> <br />5340.00 <br /> <br />5162.00 <br /> <br />5 Last month line 6C, if it was negative. . . . . . . . . 5 <br />( J check when ending loss reporting <br /> <br />6 Adjusted Sub-Total (line 4 minus line 5) . . . . . . . 6 <br /> <br />0.00 <br /> <br />5340.00 <br /> <br />5162.00 <br /> <br />7 Interest. dividends and other income. . . . . . . . . . 7 <br /> <br />12.80 <br /> <br />8 Tipboards. . . . . <br /> <br />. . . . . . . 8 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />9 Pulltabs . . . . . . <br /> <br />. . . . . . . 9 <br /> <br />303412.00 <br /> <br />248080.00 <br /> <br />10 Totals (add Jines 6, 7,8,9). . . . . . . . . . . . . .10 <br /> <br />308764.80 <br /> <br />253242.00 <br /> <br />Gl <br /> <br />(C) Net <br /> 0.00 <br /> 0.00 <br /> 178.00 <br /> 178.00 <br /> 0.00 <br /> 178.00 <br /> 12.80 <br /> 0.00 <br />55332.00 <br />55522.80 <br /> <br />11 Gambling tax on Bingo, Raffies and Paddletickets (8.5% ofline 6C) . . . . . . . . . . . . . . . . . 11 15.13 <br /> <br />12 Combined Receipts tax (Schedule E, line 9) . . . . . . . . . . . . . . . . . . . . . . . . <br /> <br />13 Pay This Amount (line 11 plus line 12) Check payable to Minnesota Revenue . . . . . . <br /> <br />14 Gambling tax paid through distributors for Pulltabs & Tipboards. . . . . . . . . . . . . . <br /> <br />15 Total gambling tax (add lines 13 and 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 <br /> <br />16 Gross profit after tax (line JOC minus line 15) and to line 17 on page 2 . . . . . . . . . . . . . . . 16 <br /> <br /> <br />Executi <br /> <br />Signature <br />Preparer <br /> <br />.~ <br /> <br />\ffi <br /> <br />Mail with attachments to: Minnesota Revenue, Mail Station 3350, St.Paul, MN 55146 - 3350 <br /> <br />12 <br /> <br />15474.66 <br /> <br />13 <br /> <br />15489.79 <br /> <br />14 <br /> <br />8050.12 <br /> <br />23539.91 <br /> <br />31982.89 <br /> <br />Date <br />5-/5-03 <br /> <br />Phone: 612-439-1439 <br />Date <br /> <br />Phone: 612-429-4116 <br />