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<br />t <br /> <br />MINNESOTA Department of Revenue <br />Monthly Lawful Gambling Activity <br />Summary and Tax Return <br /> <br />G-1 <br /> <br />Organization License Number <br />00584 <br /> <br />Month and year reported <br />11/2002 <br /> <br />Number of premises <br />6 <br />City State Zip Code <br />SPRING LAKE MN 55432 <br /> <br />[ j have you an extension to file <br />[ ] this is your final return <br />[ ] Schedule F <br /> <br />Organization Name <br />SPRING LAKE PARK LIONS CLUB <br /> <br />Street (Address) <br />8433 CENTER DR. <br /> <br />Check if: [J this is an amended return <br />[ ] you had no gambling activity <br />[ ] Schedule B-2 <br /> <br />Number of pulltab and paddleticket games <br />reported on Schedule B-2s for the month: <br />This return includes (check): <br />Fill in number of pages below each schedule: <br /> <br />961 <br /> <br />[ ] Schedule A <br /> <br /> Column A <br /> gross receipts <br />1 Bingo 1 0.00 <br />2 Raffles (if exempt raffles were conducted, <br /> check here [ ] and complete Schedule ER 2 0.00 <br />3 Paddletickets 3 405750.00 <br />4 Add lines 1 through 3 4 405750.00 <br />5 If line 6c of 18st month's Form G-1 is negative, <br /> list it in columns A and C 5 0.00 <br />6 Subtract line 5 from line 4 6 405750.00 <br />7 Income from interest and dividends (fill <br /> in same amount in columns A and C) 7 0.00 <br />8 Tipboards 8 0.00 <br />9 Pulltabs 9 619615.00 <br />10 Add lines 6 through 9. Line 1Dc is your <br /> gross profit for the month 10 1025365.00 <br />11 Multiply line Be by .085 (8.5%) <br /> (if line 6c is a negative number, fill in zero here) <br /> <br />Column B <br />prizes <br /> <br />0.00 <br /> <br /> Column C <br /> net receipts <br /> 0.00 <br /> 0.00 <br /> 51799.00 <br /> 51799.00 <br /> 0.00 <br /> 51799.00 <br /> 0.00 <br /> 0.00 <br /> 123031.00 <br /> 174830.00 <br />11 4402.92 <br />12 31600.36 <br />13 36003.28 <br />14 10099.74 <br />15 46103.02 <br />16 128726.98 <br /> <br />0.00 <br /> <br />353951.00 <br /> <br />353951.00 <br /> <br />353951.00 <br /> <br />0.00 <br /> <br />496584.00 <br /> <br />850535.00 <br /> <br />12 Fill in the amount of combined receipts tax, if any (from line 9 Schedule E) <br /> <br />13 Add lines 11 and 12, and PAY THIS AMOUNT. (Make check out to Department of Revenue) <br /> <br />14 Total 1. 7 percent tax paid during the month, if any (listed on distributor's invoices <br />for pulltabs and tipboards) <br /> <br />15 Addlines13and14 <br /> <br />16 GROSS PROFIT after state taxes (subtract line 15 from line 10c) <br />Fill in the result here and also on line 17 on the back of this form. <br /> <br /> <br />Mall this summary and tax return and attachments to <br />Minnesota Department of Revenue, Mail Station 3350. St. Paul, MN 55146-3350 <br />6001000 (Rev. 07199) <br /> <br />Minnesota Gambler <br />