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<br />to <br /> <br /> <br />ervi((e <br />,;~c~ <br />'Esta6fisliei 1857 <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />Organization Name: 1)~ ~ let ~dW: Cv\.l& <br /> <br />FJ:a ~-.j <R- ii) J~:\n.';l"'!'l <br />, l'l,i'; ,,) ,illl!') <br />>M ~ e.: ~ :..,;,.1,,, <br /> <br />Gambling Location: <br /> <br />1\~~ :tf.J;..J <br />\ "" }Ol...- <br /> <br />MonthlYear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />. t;r..Atu'" LA,) 1Z<Ju.-~! CPA <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A. <br /> <br />Net Receipts - TotalIines 2c, 3c, 8c, 9c <br />(per Schedule A if more than one (l ) site) <br /> <br />b z. ~ 2... <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (1 ) site) <br /> <br />L.fSL\ \ <br /> <br />c. <br /> <br />Line a - line b <br /> <br />~lt..\\ <br /> <br />Miscellaneous Deductions (for this site only) <br />1. Pulltab tax to distributor ~ <br />2. Combined receipts tax for this site ZSD4 <br /> <br />3. Federal Taxes (per schedule C/D) <br /> <br />4. <br /> <br />State Gambling Tax (per line IlL <br /> <br />5" <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />L}-z. 7:J 1- <br /> <br />< .Z}-\cn ') <br /> <br />\IL.-L-t ~ ') <br /> <br />E. <br /> <br />Line c - line d <br /> <br />40% <br /> <br />< cpn ') <br />( 1 L\~ ') <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />10% <br /> <br />Signature: <br /> <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />r) M <br />I \ r t . nO r <br />~rl ~ .. <br /> <br />