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<br />MONTHLY SUMMARY and TAX RETURN (G-l) <br />Lawful Gambling Activity <br /> <br />Month and Year Premises <br />FEBRUARY 2002 3 <br />Address <br />19680 Harrow Avenue North. Forest lake MN 55025 <br />Attached: Schedule A Schedule B2 Schedule F <br />381 <br /> <br />(A) Gross (B) Prizes (C) Net <br />1 0.00 0.00 0.00 <br /> <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 />95 <br /> <br />1 Bingo. <br /> <br />2 Raffles [ J Exempt, Schedule-ER <br /> <br />2 0.00 <br />3 1,260.00 <br />4 1,260.00 <br />5 0.00 <br />6 1,260.00 <br />7 31. 93 <br />8 0.00 <br />9 160,940.00 <br />.10 162,231. 93 <br /> <br />3 Paddletickets. . . . <br /> <br />4 SUB-TOTAL (Add lines 1 through 3). <br /> <br />5 last Month Line 6C, if it was negative <br />6 Adjusted Sub-Total (Line 4 minus Line 5) <br /> <br />7 Income from Interest and Dividends <br /> <br />8 Tipboards. <br />9 Pu lTtabs . <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 />1,218.00 <br />1,218.00 <br /> <br />1,218.00 <br /> <br />0.00 <br />132,151.00 <br />133,369.00 <br /> <br />13 PAY THIS AMOUNT (Line 11 plus Line 12) Check to Department of Revenue. 13 <br /> <br />14 Gambling Tax Paid to Distributors for Pulltabs & Tipboards <br /> <br />15 TOTAL Gambling Tax (Add Lines 13 and 14) . . . <br /> <br />0.00 <br />42.00 <br />42.00 <br />0.00 <br />42.00 <br />31. 93 <br />0.00 <br />28,789.00 <br />28,862.93 <br /> <br />11 <br />12 <br /> <br />3.57 <br />8,209.57 <br />8,213.14 <br />2,347.68 <br /> <br />14 <br /> <br />15 10,560.82 <br /> <br />16 GROSS PROFIT, After Taxes (line 10C minus Line 15) to line 17, page 2. 16 18,302.11 <br /> <br /> <br />tion on this sUlllnar and return is true ~.correct and c 1 te. <br />Date Signature &- c.. Date-,.. <br />'].-('i'-'p7-- Gamblin /-( .c'_______ ,07.-/7....>::::.. <br />IDa e Phone Preparer ID number <br />'1., z, 01.. l"Sk1So' -a:::~ n s <br />Mail Station 3350, StPaul, MN 55416-3350 <br />