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<br />r <br /> <br /> <br />'iiJY 'E,'lll!ifi4icd iSS,- <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />Organization Name: <br /> <br />IA';'" /' ~"" /' 'C. ,,,,/',- .-, ,/' .'J <br />t7 ~j [ I,. 1/7 '>0-/-,: ,,'~ :_~'I_ ,-' ,~ ,t. ..<__ <br />,,~...-,.: Ie /,,' ;>-"--".'~.-/l' j -.'__-'J. ........-;.;~.i :__ i,'., ".'__' __""_/ .1... -' <br /> <br />Gambling Location: <br /> <br />t/,J -r S f~ <br /> <br />(~!~ I, ,,~ ( ,~ l; <br />~-' -' .,,/ <br /> <br />l:>~ ." -. ,1 <br />\ l,..-.0-' (, :7'~ <br />. - <br /> <br />'I i .., <br />\ \ \ tl..-' <br /> <br />MonthlYear: <br /> <br />Name ofIndividual Completing Form: <br /> <br /> <br />Ten Perf'ent Net Pron Calculation <br /> <br />A. <br /> <br />Net Receipts - Total lines 2c, 3c, 8c, 9c <br />(per Schedule A if more than oae (1 ) site) <br /> <br />[-Ii. . <br />~_.L''--;l <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (l ) site) <br /> <br />, <br />;") ": -, <br />~. .; '-.- <br /> <br />C. Line a - Ene b <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />1. Pulltab tax to distributor <br /> <br />2. <br /> <br />Combined receipts tax for this site <br /> <br />C~-J -:) <br /> <br />3. Federal Taxes (per schedule CfT)) <br /> <br />4. <br /> <br />State Gambling Tax (per line 11) <br /> <br />2 <br /> <br />D. Total Miscellaneous Deductions for this site <br /> <br />E. <br /> <br />Line c - line d <br /> <br />----J --7 -; <br /> <br />::.;. -.:.:~) <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />40% <br /> <br />, ~ <br />\ :; <br /> <br />List Receivers of filnds/or attach a <br /> <br />separate page <br /> <br />10% <br /> <br />...--.-;' <br />~ ::~ <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: <br /> <br />