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<br /> <br />. <br /> <br />ervi{{e <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />y~ ~ St.l((,~<' C.-ve <br />W~G;.yl.lJ~ f:J:'"2.~ <br />I G" ! l) '"L- <br /> <br />Gambling Location: <br /> <br />MonthlY ear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />~,Jf U, \ZwV;;43; \ Cf'~ <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A. <br /> <br />Net Receipts - Total lines 2c, 3c, 8c, 9c <br />(per Schedule A if more than one (l ) site) <br /> <br />LSlt.i <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A ifmore than one (1) site) <br /> <br />Line a-line b <br /> <br />L.~!oO <br /> <br />c. <br /> <br />( 'L~~ ) <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />2. <br /> <br />Combined receipts tax for this site <br /> <br />5"g 1 <br />1t.-/~ <br /> <br />1. <br /> <br />Pulltab tax to distributor <br /> <br />3. Federal Taxes (per schedule C/D) <br /> <br />4. <br /> <br />State Gambling Tax (per line 11) <br /> <br />1- <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />')'2.., <br /><Har~ I <br />(Yo1'; <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />E. <br /> <br />Line c - line d <br /> <br />40% <br /> <br />< ~t1S ) <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />10% <br /> <br />\,)(g 'L ') <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: ~ ~ <br />