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<br />, <br /> <br />, <br />, <br /> <br /> <br />N~tervi[{e <br /> <br />Tsta6(L<lid lff5i <br /> <br />Gambling Location: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />- . I <br />,'S O';,"I'Vlq!.?ike Je:iv'K.' L.'cv.< <br />! -J <br />k;0r <br /> <br />TC-t~ <br /> <br />2. dO 2- <br /> <br /> <br />jf)",,,,,,, <br /> <br />k~ JI",y <br /> <br />Organization Name: <br /> <br />MonthlY ear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A. <br /> <br />Net Receipts - Total lines 2c, 3c, 8c, 9c <br />(per Schedule A if more than one (I ) site) <br /> <br />Sums of lines 22 tjrru 33 <br />(per Schedule A if more than one (I) site) <br /> <br />l'} v" ~ <br />"7 l.Ob".4..t () <br /> <br />B. <br /> <br />.'J ''',' /V'" <br />116 "';"1.-J.~ ~_.;!t..J <br /> <br />C. <br /> <br />Line a - line b <br /> <br />d, 'J.. tJo <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />L Pulltab tax to distributor <br />3CJ/~rb)l. t.7 <br />2. Combined receipts tax for this site <br />eow br ~('J 'teef'r ~ f"7!~.-X ).~ i <br />3. Federal Taxes (per schedule CID) <br /> <br />S' )?dO <br /> <br />17. (1 0 <br /> <br />4. <br /> <br />State Gambling Tax (per line 11) <br /> <br />L('Z.00 <br /> <br />D. Total Miscellaneous Deductions for this site <br /> <br />E. <br /> <br />Line c - line d <br /> <br />./ bn. <br /> <br />'" <br />/' <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />- <br /> <br />40% <br /> <br />List Receivers of fimds/or attach a <br />separate page <br /> <br />10"/0 <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: <br /> <br />,/ <br />. [;:'U-y/. <br /> <br />j /{i: <br />'~e'. i:1~.. <br /> <br />~ <br />