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<br />~" <br /> <br />.. <br /> <br /> <br />.r....tabti..;/;..,( J.'i:;;- <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />~~ ~~'E. ~l...C Cl..\)j'$ <br /> <br />~S\1l. G.u"1s P1:2zv\ <br />zle3 <br /> <br />Gambling Location: <br />MonthlY ear: <br /> <br />Name of Individual Completing Fonn: <br /> <br />$UtJ\ V-). es~ ~ eRA <br /> <br />TeD Percent Net Profit Calculation <br /> <br />A Net Receipts- Total lines 2c, 3c, 8c, 9c <br />(per Schedule A ifmore than one (1) site) <br /> <br />B. Sums ofHnes 22 thru 33 <br />(per Schedule A ifmore than one (I) site) <br /> <br />C. Line a -line b <br /> <br />, S 5~7... <br />I <br /> <br />3L-f 'Z. , <br /> <br /><"3"1) <br /> <br />MisceUaneous Deductions (for this site only) <br /> <br />1. <br /> <br />Pulltab tax to distnoutor <br /> <br />3\1 <br />~~I <br /> <br />2. <br /> <br />Combined receipts tax for this site <br /> <br />3. Federal Taxes (per ~hedule C1D) <br /> <br />4. State Gambling Tax (per line II) <br />S. I~ ~ V:...Jt.Jfj <br />Total Miscellaneous Deductions for this site <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />3 <br /><1"~ <br /> <br />< :sq ~ ) <br />< \~~ '> <br /> <br />D. <br />E. <br />F. . <br /> <br />Line c -line d <br /> <br />400A>> <br /> <br />< \51 ') <br /> <br />List Receivers of fimdslor attach.a <br />separate page <br /> <br />1 OOAl <br /> <br />(~'1) <br /> <br />-,j <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />SPure: ~~ <br />