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<br />MONTHLY SUMMARY and TAX RETURN (G-I) <br />lawful Gambling Activity <br /> <br />Month and Year Premises <br />DECEMBER 2002 4 <br />Address <br />19680 Harrow Avenue North. Forest lake MN 55025 <br />Attached: Schedule A Schedule B2 Schedule F <br />4 19 1 <br /> <br />(A) Gross (B) Prizes (e) Net <br />. 1 0.00 0.00 0.00 <br /> <br />, .. <br /> <br />MINNESOTA DEPARTMENT OF REVENUE <br /> <br />Organization license <br />03800 <br />Name <br />Dead Broke Saddle Club <br />Schedule B-2 Game Count <br />220 <br /> <br />1 Bingo. <br /> <br />.,.......... <br /> <br />2 Raffles [ ] Exempt, Schedule-ER . . . . . 2 <br /> <br />3 Paddletickets. . . . <br /> <br />3 <br />. 4 <br />5 <br /> <br />4 SUB-TOTAL (Add Lines 1 through 3). <br /> <br />5 last Month line 6C, if it was negative <br /> <br />6 Adjusted Sub-Total (line 4 minus line 5) . 6 <br />7 Income from Interest and Dividends . . . . 7 <br /> <br />8 Tipboards. . <br />9 Pulltabs . <br /> <br />. 8 <br /> <br /> <br />......9 <br /> <br /> <br />.10 <br /> <br />10 TOTALS (Add lines 6,7,8,9) . <br /> <br />11 Gambling Tax (8.5% of line 6C) <br /> <br />12 Combined Receipts Tax (Schedule E, line 9) <br /> <br />0.00 <br />3,660.00 <br />3,660.00 <br />0.00 <br /> <br />3,660.00 <br />21. 35 <br />0.00 <br />305,678.50 <br />309,359.85 <br /> <br />0.00 <br />3,538.00 <br />3,538.00 <br /> <br />3,538.00 <br /> <br />0.00 <br />250,774.00 <br />254,312.00 <br /> <br />. . 11 <br /> <br />0.00 <br />122.00 <br />122.00 <br />0.00 <br />122.00 <br />21. 35 <br />0.00 <br />54,904.50 <br />55,047.85 <br /> <br />10.37 <br /> <br />. 12 15,590.69 <br /> <br />13 PAY THIS ~_~UNT (Line 11 plus Line 12) Check to Department of Revenue. 13 15,601.06 <br /> <br />15 TOTAL Gambling Tax (Add Lines 13 and 14) . . . . . <br /> <br />14 Gambling Tax Paid to Distributors for Pulltabs & Tipboards . <br /> <br />. 14 <br />15 <br /> <br />8,952.77 <br />24,553.83 <br /> <br />16 GROSS PROfIT, After Taxes (line laC minus line 15) to line 17, page 2. 16 30,494.02 <br /> <br />I eclare that all information on this summar <br />Signature ~ ..~, '\ ' ~ Date_ <br />Chief Exea~ ~ 1"'" I~ I :2:9'C?~ <br />Signature \~ . I II D~te <br />Pre arer '\ , ("510-:) (oS\ 1'S'1; Lj<ro<) <br />Mail to: MN Dept.of Revenue, Mai~ Station 3350, StPaul, MN 55416-3350 <br /> <br /> <br />correct and com lete. <br />r.- Da te <br />~ / 2.Q --OJ <br />Preparer 10 number <br />I n~$'k) <br />