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<br />l <br /> <br /> <br />,1detltervi[[e <br /> <br />~~i;,~Y'-~ 'L~~.tal{LI,/rL'd ll."~:;;'- <br /> <br />n t"f' <br />P...i-Lii,., <br /> <br />2 3 2002 <br /> <br />CITY OF C:ENTERVILLE <br />Monthly Gambling Summary <br /> <br />Organization Name: <br /> <br /> <br />Gambling Location: <br /> <br />1(~/.:~.;,~, <br /> <br />MonthlYear: <br /> <br />\ \ I c ..~... <br /> <br />Name of Individual Completing Form: <br /> <br /> <br />Ten. Perec!!t1'4c.t.' '!:QE'. Caic.~}a ti9n <br /> <br />A. Net Receipts -- Total lines 2c, 3c, 8c, 9c <br />(per ~;chedulc A iLnore than one (I ) site) <br /> <br />B. <br /> <br />Surns oflines 22 thm :3 <br />(per Schedule /- if r :ore than (IDe ( l) ,;ite) <br /> <br />C. Ijne a .- line b <br /> <br />lVlisccllaneous Deductions (fi.H this sile only) <br /> <br />J. Pullta b 1m, to distributor <br /> <br />2. <br /> <br />Combined receipts tax (()r thi,; ;)itc <br /> <br />3. <br /> <br />!~\:~der~d 'T'a;cc;; (per ~:;chcC_tile (:/D) <br /> <br />4. <br /> <br />State Gambling Tax (per Ii].~ 1 J) <br /> <br />D. Total Miscellaneous Deduction::; f{)f this site <br /> <br />E. <br /> <br />Line c .. line d <br /> <br />i <br />. , <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />A7v10UNT DUE <br /> <br />,--<. <br />- ----.-.----"- <br /> <br />40% <br /> <br />---:~ <' ~'. <br /> <br />List Receivers of [lmd /w at1~)ch a <br />separate page <br /> <br />lO(>~ <br /> <br />PA YABLE TO .rIIE CITY OF <br />CFNTERVILLE *DtJI:: ANNIJALLY <br />AS PER ORIHNANC("" <br /> <br />Signature: <br /> <br />