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<br />/~ <br />i~ ' <br />{r ".. <br /> <br /> <br />ffB2 4-2003 <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />Orgoni7aliou Name: S" r ..::::J A..1f-~ ~I: L..~ ~ <br /> <br />Gambling Location: t: J- !!:J ~ k;, ""-- --~ <br /> <br />MooIhIYear: ':r?.......-.:..s tIJ ill . <br /> <br />Name of Individual Completing Fo~ . ~ ~~ r~€~ <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A Net Receipts ..:. Total lines 2c, 3e, 8e, 9c <br />(per Schedule A if more than one (1) site) <br /> <br />B. Sums of Jines 22 tbru 33 <br />(per Schedule A if mOre than one (1) site) <br /> <br />C. Line a -line b <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />, $'4/.1.' ()O <br /> <br />! <br />. <br /> <br />"q".OD <br /> <br />21tJG. fJO <br /> <br /> 1. Pulltab tax to distributor to 72. at) <br /> 2. Combined receipts tax for this site 1 dC' .00 <br /> 3. Federal Taxes (per schedule C1D) - <br /> 4. State Gambling Tax (per line 11) :?t::I",OO <br />D. Total Miscellaneous Deductions for this site ~ i!J1"1.(Jo <br />E. Line e -line d .c :z 7'1 'i. , tI <br />F. Line e X 50% AMOUNT DUE ~ 13 'It) 00) <br /> <br />4()OJO < 54/'" ') . List ~ers offundslor'attach a <br />separate page <br /> <br />10% < J:?7:/ PAYABLE TO TIIE crrY OF <br />CENTERVllLE "'DUE ANNUALLY <br />AS PER ORDINANCE'" <br /> <br />Signature: <br /> <br />~ f'~AA /?~~ <br />