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<br />~ <br /> <br />.J <br /> <br /> <br />'L..qabl'i.~il'J" l.~ <br /> <br />Organization Name: <br />Gambling Location: <br />MonthlY ear: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />~ ~~i: ~(.a: CL."~ <br /> <br />T rz..1:O r.-.J,.J <br />7,\03> <br /> <br />.MAR 2 1 2003 <br /> <br />Name of Individual Completing Fonn: <br /> <br />.J,."UIJ'T W. j1,,~,J" ~ <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A Net Receipts -. Total lines 2e, 3e, Se, 9c <br />(per Schedule A ifmore than one (1) site) <br /> <br />B. Sums of lineS 22 thru33 , <br />(per Schedule A if more than one (1 ) site) <br /> <br />C. Line a -line b <br /> <br />5113 <br /> <br />1..\135 <br /> <br />3l~ <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />1. <br /> <br />PuDtab tax to distributor <br /> <br />'1~9 <br />Il,'z- S <br /> <br />-.,.,..:,..._.' <br /> <br />2. <br /> <br />Combined receipts tax for this site <br /> <br />3. Federal Taxes (per schedule C/O) <br /> <br />4. State Gambling Tax (per line 11) <br />S. Ttu '" 'H4'VfoJl) <br />Total Miscellaneous Deductions for this site <br /> <br />Line e X 50% <br />4()OAa (~D) <br /> <br />IOOAa < If; l <br /> <br />AMOUNT DUE <br /> <br />5 <br />< ISJoiO) S2~ <br /> <br />~ <br />( 15 '> <br /> <br />- <br /> <br />\ <br /> <br />D. <br />E. <br />F. <br /> <br />Line e -line d <br /> <br />List Receivers offundslor attach a <br />separate page <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE. *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: <br /> <br />~pwlUlJ <br />I <br />