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<br />~ <br /> <br /> <br />APR 2 1 2003 <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />1JMo ~~ ~t4 c.~ <br /> <br />Gambling Location: <br /> <br />~ --. <br />'0;-\.-0 J.:.fJ N <br />~lo3 <br /> <br />MonthlYear: <br /> <br />Name of Individual Completing Form: <br /> <br />~.Ji W l2vt,L,1=-r ~ ,C~ <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 />CJS~2 <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (1) site) <br /> <br />Lfs~Oj <br /> <br />c. <br /> <br />Line a - line b <br /> <br />5o~~ <br /> <br />MisceUaneous Deductions (for this site only) <br /> <br />1. <br /> <br />Pulltab tax to distributor <br /> <br />\ 'Z,S L-J <br />1~~, <br /> <br />2. <br /> <br />Combined receipts tax for this site <br /> <br />3. Federal Taxes (per schedule C/O) <br /> <br />4. <br /> <br />State Gambling Tax (per line II) <br /> <br />s <br /> <br />E. <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />)q~l, <br />'0'\1 <br />S '--\~ <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />Line c -line d <br /> <br />40% <br /> <br />Y3~ <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />10% <br /> <br />10'1 <br /> <br />PAY ABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: <br /> <br /> <br />~.~ <br />