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<br />MINNESOTA DEPAR11I:NT OF" REVENUE <br /> <br />. <br />MONl1I.Y SUlllARY and TAX RETURN (G-I) <br />Lawful Gambling Activity <br />Month and Year Premi~es <br />JANUARY 2003 4 <br />Address... " <br />19680 Harrow Avenue North. Forest Lake MN 55025 <br />Attached: Schedule A Schedule B2 Schedule F <br />4 .24 1 <br /> <br />Organization License <br />03800 . - <br />Name" <br />Dead Broke Saddle Club <br />Schedule B-2 Game Count <br />285 . <br /> <br />1 Bingo. . <br /> <br />............. <br /> <br />(A) Gross (B) Prizes (C) <br />. . . . 1 0.00 0.00 <br /> <br />2 Raffles [ ] Exempt, Schedule-ER . . . . . 2 <br />3 Paddletickets. . . . . . . . . . . . . . . 3 <br />4 SUB-TOTAL (Add Lines 1 through 3). . . . . 4 <br />5 Last Month Line 6C, if it was negative ~ . 5 <br />6 Adjusted Sub-Total (Line 4 minus ~1ne 5) . 6 <br /> <br />7 Income from Interest and Dividends . <br /> <br />. 7 <br /> <br />8 Tipboards. <br />9 Pulltabs . <br /> <br />. . . <br /> <br />...... <br /> <br />.....8 <br /> <br />...... <br /> <br />....9 <br /> <br />. . . <br /> <br />. . . <br /> <br />0.00 <br />5,970.0Q <br />5,97().00 <br />0.00 <br />5,970.00 <br />17.21 <br />0.00 <br />294,358.00 <br /> <br />0.00 <br />5,771.00 <br />5,771.00 <br /> <br />5,771.00 <br /> <br />0.00 <br />237,426.00 <br /> <br />Net <br />0.00 <br /> <br />0.00 <br /> <br />199.00 <br /> <br />199.00 <br /> <br />0.0'0 <br /> <br />199.00 . <br /> <br />17.21 <br /> <br />0.00 <br /> <br />56,932.00 <br /> <br />10 TOTALS (Add Lines 6,7,8,9) . . . . . . . .10 300,345.21 243,197.00 57,148.21 <br /> <br />11 Gambling Tax (8.51 of Line 6C) . <br /> <br />............. <br /> <br />.11 <br /> <br />12 Combined Receipts Tax (Schedule E, Line 9) . . . . . . . . . . . . 12 <br />13 PAY THIS ANQUNT (line 11 plus Line 12) Check to Department of Revenue. 13 <br />. 14 <br /> <br />14 Gambling Tax Paid to Distributors for pulltabs &. Tipboards . . <br />15 TOTAL Gambling Tax (Add Line$ 13 and 14) . . . . . . . . . . . . . <br /> <br />. . . <br /> <br />. . 15 <br /> <br />16 GROSS PROFIT, After Taxes (Line lot minus Line 15) to line 17, page 2. 16 <br /> <br />16.92 <br />15,013.13 <br />15,030.05 <br />6,()68.25. <br />21,098.30 <br />36,049.91 <br /> <br /> <br />k <br /> <br />r <br />