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<br />MINNESOTA DEPARTMENT Of REVENUE
<br />
<br />MONTHLY SUMMARY and TAX RETURN (G-1)
<br />lawful Gambling Activity
<br />
<br />Premises
<br />4
<br />
<br />Organization License
<br />03800
<br />Name
<br />Dead Broke Sa~lub
<br />Schedule B-2 Game Count
<br />193
<br />
<br />Month and Year
<br />NOVEMBER 2002
<br />Address
<br />19680 Harrow Avenue North. Forest lake MN
<br />Attached: Schedule A Schedule B2
<br />4 16
<br />
<br />55025
<br />Schedule F
<br />1
<br />
<br />1 Bingo.
<br />
<br />.. .. .. . .. .. .. .. .. ..
<br />
<br />(A) Gross (B) Prizes (C) Net
<br />1 0.00 0 . 00 0 . 00
<br />
<br />2 Raffles [ ] Exempt, Schedule-ER
<br />3 Paddletickets.
<br />
<br />2 0.00
<br />3 3,390.00
<br />4 3,390.00
<br />5 0.00
<br />I" 3,390.00
<br />u
<br />7 40.00
<br />8 0.00
<br />9 259,770.00
<br />.10 263,2)0.00
<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)
<br />
<br />7 Income from Interest and D Jidends
<br />
<br />11 Gamblin~ Tax (8.5% of line Ge)
<br />
<br />12 Combin~~d Receipts Tax (Schedule E, Line 9)
<br />
<br />0.00
<br />3,277.00
<br />3,277.00
<br />
<br />0.00
<br />113.00
<br />113.00
<br />
<br />0.00
<br />
<br />3,2/l.00
<br />
<br />113.00
<br />
<br />40.C:.1
<br />
<br />0.00
<br />
<br />49,749.00
<br />
<br />49,902.00
<br />
<br />.11
<br />
<br />9.61
<br />
<br />12 13,250.31
<br />
<br />13 PAY THIS AMOUNT (L ine 11 plus Une 12) Check to DerH(tt<~nt of Rev<:'nue. 13 13,259.92
<br />
<br />14 Gambling Tax Paid to Distributors for Pulltabs & Tipboards
<br />
<br />15 TOTAL Gambling Lx (,L\dd Lines 13 and 14) . . .
<br />
<br />3,650.12
<br />
<br />14
<br />
<br />15 16,910.04
<br />
<br />16 GROSS PROFIT, After Taxes (Line 10C minus Line 15) to line 17, page 2. 16 32,991.96
<br />
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<br />Slgnature&{\f:y;,,--?>;:!ji i - )(10. Date SlgnatUrE: l/'/ /~///' Date '7 --">j
<br />.. /.x./-, "/''-<'' ,/ / 1" _,." . . .,J~" .,.'67 ,t:'/' L."--; '.-. 'J'I,;~. .~",;
<br />ct. f E / #~'" ".,~- ,j ,/,V L: .-- I "_-, 19 ff'" G'I,,"-l"I'-' '19'1 \, "-'7, ,/" ~'l, < -.' -~ / <'- I., " v",
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<br />_l~,~)2.~,-", /" -rtIZ "," -~- -_._-----.~---,,---.._-,.]-..- h,__"""_'~'-<::::'__ -----------,.-------------.---
<br />Signature\~, (I") /Ii'{/ I wt\ Phone Pl'eparer 10 number
<br />, \ .-,,-c~c;,: /"-.J \J Y u: en./' . f'l - l- . <) n l-{ '5 ~ 0
<br />PrfilliU,IT-, _____..:-..-_, ___Jk1.h-_ _"'_____It&.L:L&.:l$'Li-_--, I --
<br />Mail to: M. Dept. of Revenu e, MJil 5th ion 3350, StP au I, MN 554 \ 6.3350
<br />
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