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<br />" <br /> <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling $nmmary <br />. Olpni~tionName: . ~. ~a. ~ ~ <br />T ~ ~..J <br />,[0'3 <br /> <br />Gambling Location: <br /> <br />MonthlY ear: <br /> <br />NameoflndividuaI Completing Form: <br />Ten Percent Net Profit Calculation' <br /> <br />~'\ \,.} ~, C'h <br /> <br />. I <br /> <br />A Net Receipts - Total Jines 2c; 3c, 8c, 9c <br />(per Schec:iule A it D1()re than one (1) site) <br /> <br />B. Sums oflines 22 tbru 33 <br />(per Schedule A itmore than one (1) site) <br /> <br />C. Linea-lineb <br /> <br />Miscellaneous Deductions (for this site o~) <br /> <br />1. PuDtab tax to distributor III <br /> <br />2. Combined receipts tax for this $ite -' (, ~O <br /> <br />fu1-~2 <br />~1l.( 1 <br />--.l'1l5 <br /> <br />D. <br />E. <br />F. <br /> <br />3. Federal Taxes (per schedule CID) <br />4. State Gambling Tax: (per line 11) 1 <br />Total Miscellaneous Deductions for this site <br />Line c - line d <br /> <br />Line e X SOOA <br />40% < ?'45 ') <br /> <br />AMOUNT DUE <br /> <br />'Z1t.it <br />\iftJl) <br /><~1>\1 <br /> <br /><. 'l~) <br /> <br />List Receivers offimdslor attach a <br />separate page <br /> <br />PAYABLE TO TIIE CITY OF <br />CENTERVILLE *Dm: ANNUALLY <br />AS PER ORDINANCE* <br /> <br />10% <br /> <br />S~~~. <br />