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<br />MONTHLY SUMMARY and TAX RETURN (G-I) <br />Lawful Gambling Activity <br /> <br />Month and Year Premises <br />MARCH 2003 5 <br />Address <br />19680 Harrow Avenue North. Forest LakeMN 55025 <br />Attached: Schedule A Schedule 82 Schedule F <br />5 25 . 1 <br /> <br />(A) Gross (B) Prizes (C) Net <br />· · 1 0.00 0.00 0.00 <br /> <br />. <br /> <br />MINNESOTA DEPARTMENT OF REVENUE <br /> <br />Organization license <br />03800 <br />Name <br />Dead Broke Saddle Club <br />Schedule B-2 Game Count <br />311 <br /> <br />1 Bingo. <br /> <br />........... . <br /> <br />2 Raffles [ ] Exempt, Schedule-ER . <br /> <br />. . 2 <br /> <br />3 Paddletickets. . . . <br /> <br />. . . . 3 <br /> <br />4 SUB-TOTAL (Add lines 1 throug~ 3). <br /> <br />. . 4 <br /> <br />5 Last Month Line 6C, if it was negative . 5 <br />6 Adjusted Sub-Total (line 4 minus Line 5) . 6 <br />7 Income from Interest and Dividends . . . . 7 <br /> <br />8 Tipboards. <br />9 Pulltabs . <br />10 TOTALS (Add lines 6,7,8,9) . <br /> <br />. . 8 <br /> <br />. . 9 <br /> <br />.10 <br /> <br />11 Gambling Tax (8.5% of Line 6C) <br /> <br />0.00 <br />6,330.00 <br />6,330.00 <br />0.00 <br />6,330.00 <br />12.30 <br />0.00 <br />293,744.00 <br />300,086.30 <br /> <br />0.00 <br /> <br />6,119.00 <br />6,119.00 <br /> <br />6,119.00 <br /> <br />0.00 <br />239,186.00 <br />245,305.00 <br /> <br />11 <br />. 12 <br /> <br />............... . <br /> <br />12 Combined Receipts Tax (Schedule E, Line 9) <br /> <br />0.00 <br />211.00 <br />211.00 <br />0.00 <br />211.00 <br />12.30 <br />0.00 <br />54,558.00 <br />54,781.30 <br /> <br />17.94 <br />14,981.58 <br /> <br />13 PAY THIS AMOUNT (line 11 plus line 12) Check to Department of Revenue. 13 14,999.52 <br /> <br />14 Gambling Tax Paid to Distributors for Pulltabs & Tipboards <br />15 TOTAL Gambling Tax (Add lines 13 and 14) . . . . . . . ~ . . <br /> <br />. 14 6,177.36 <br />. . 15 21,176.88 <br /> <br />16 GROSS PROFIT, After Taxes (line 10C minus line 15) to line 17, page 2. 16 33,604.42 <br /> <br /> <br />tion on this summar and return is true <br />Date Signature <br />