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<br />"" <br /> <br />, <br /> <br />MINNESOTA Department of Revenue <br />Month"ly Lawful Gambling Activity <br />Summary and Tax Return <br /> <br />G-1 <br /> <br />0tganizatJ0n LIcense Number <br />00584 <br />OrganJzatlon Name <br />SPRING LAKE PARK UONS CLUB <br />Number of pul/lab and paddJetJcket games <br />reported on Schedule 8-28 for the month: <br />ThIs tetum Includes (check): <br />FT8/n numberof pages below each schedule: <br /> <br />Month and year reported <br />1/2003 <br />SI1eet (Address) <br />B433 CENTER DR. <br /> <br />CIly <br />SPRING LAKE <br /> <br />Number of premises <br />6 <br />State "" ZIp Code <br />MN 55432 <br /> <br />Check If: <br /> <br />{ J this Is an amended tetum <br />{ J you had no gambling actIvify <br />[ J Schedule 8-2 <br /> <br />{ J have you an eldansIorJ to file <br />{ J this Is your finaJ tetum <br />{ ] Schedule F <br /> <br />872 <br />{ J Schedule A <br /> <br /> Column A Column B Column C <br /> g1D88 receipts prizes net receipts <br />1 Bingo 1 0.00 0.00 0.00 <br />2 Raffles (if exempt raffles were conducted, <br /> check here [ J and complete Schedule ER 2 0.00 0.00 0.00 <br />3 Paddletlclcets 3 370635.00 323019.00 47616.00 ( <br />4 Add lines 1 through 3 4 370635.00 323019.00 47616.00 <br />6 if Une Be of last month's Form G-1 is negative, <br /> list it In columns A and C 6 0.00 0.00 <br />6 Subtract line 5 from line 4 6 370635.00 323019.00 47616.00 <br />7 Income from Interest and cflVidends(fiIl <br /> in same amount In columns A and C) 7 0.00 0.00 <br />8 npboards 8 0.00 0.00 0.00 <br />9 Pulltabs 9 510732.00 415020.00 95712.00 <br />10 Add lines 6 through 9. Une 10e is your <br /> g1D88 profit for the month 10 881367.00 738039.00 143328.00 <br />11 Multiply line Be by .085 (8.5%) <br /> (if Une Be is a negative number, fill in zero here) 11 4047.36 <br />12 FiU In the amount of combined receipts tax, If any (from line 9 Schedule E) 12 26047.34 <br />13 Add lines 11 and 12, and PAY THIS AMOUNT. (Make check out to Department of Revenue) 13 30094.70 <br />14 Total 1. 7 percent tax paid during the month, If any (Usted on distributors invoices <br /> for pulltabs and tlpboa<<!B) 14 9044.99 <br />15 Add lines 13 and 14 16 39139.69 <br />16 GROSS PROFIT after state taxes (subtract lint!' 15 from One 10e) <br /> Fill in the result here and also on line 17 on the back of this form. 16 104188.31 <br />I declare that aI/Information on this summary and tax retum is true, correct. and complete. <br />Slgna1w8 of chief executive offictIr Dete Slgna1w8 of gambling manager Date <br />Preparer's signature Dete DaytIme phone Preparer's ID number <br /> <br />Mail this summary and tax retum and attachments to <br />Minnesota Department of Revenue, Mall Station 3350. St Paul, MN 55146-3350 <br />6001000 (Rsv. 07199) <br /> <br />Mblesata Gambler <br />