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<br />~. <br /> <br /> <br />ffBc 2 . i 2OtU. <br /> <br />CITY OF CENTERVILLE <br />Monthly GambliDg Sum~ary . <br />OrgIIn:~tionName: ~:~ ~G..va <br />Grmhm,g Location: W:f'!>~ ~ \'t:'2141 <br />MonthlY ear: c/ 0 ;, <br /> <br />Name of Individual Completing Form: <br />TeD PereeBt Net Profit CalculatlOD <br /> <br />~ ~ ~ ,CP1*r <br /> <br />A Net Receipts - Total lines 2c, 3c, Be, 9c <br />(per Scbedule A jfmore than one (1) site) <br />B. Sums of Jines 22 thm 33 <br />(per Schedule A jfmore than one (1) site) <br />C. Line a -line b <br />. MisceDaneous Deductions (for this site only) <br />1. PuBtab tax to distributor ~ 11 <br />2. Combined receipts tax fur this site ~ <br /> <br />1~t.I <br /> <br />~-, <br /> <br /><7.k~1:>'> <br /> <br />3. Federal Taxes (per schedule 00) <br />4. State Gambling Tax (per line 11) L <br /> <br />Line e X SO'Aa <br />400At < ,t.\ ~ \ ') <br /> <br />10'At < 1,r::1 'J <br /> <br />AMOUNT DUE <br /> <br />~ <br /><'3~'; <br />< \1to&.t ') <br /> <br />Total MisceDaneous Deductions for this site <br /> <br />D. <br />E. <br />F. <br /> <br />Line c - line d <br /> <br />List Receivers of fimdS/or attach a <br />separate page <br /> <br />Signature: <br /> <br /> <br />PAYABLE TO TIIECITYOF <br />CENTERVIILE .DUE ANNUAUY <br />Q ORDINANCE. <br />