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<br /> <br />'I:\ldl~i.,I;l..t IS:;;- <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />~.-/rC ~~ ~ C\"V~ <br /> <br />~(~v'1S ~~ <br />b\O~ <br /> <br />Gambling Location: <br /> <br />MonthlYear: <br /> <br />Name of Individual Completing Form: <br /> <br />~,.fi W \2uu-~1 cFp. <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 />3~'5D <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (] ) site) <br /> <br />~~l5 <br /> <br />c. <br /> <br />Line a - line b <br /> <br />~l~ <br /> <br />Miscellaneous Deductions (for this site only) <br />1. PuUtab tax to distributor ,~~ <br />2. 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 11) <br /> <br />5' <br /> <br />40% <br /> <br />L.ine e X 50% <br /> <br />( 1~1 <br />< 3) <br /> <br />AMOUNT DUE <br /> <br />'1'~ <br /><~ll <br />{ r~) <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />E. <br /> <br />Line c - line d <br /> <br />F. <br /> <br />List Receivers offunds/or attach a <br />separate page <br /> <br />10% <br /> <br />PAY ABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: <br /> <br />