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<br />- -- .-- -.l <br /> <br />MiNNESOTA Department of Revenue <br /> <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 />7 I 2002 <br />Street (Address) <br />8433 CENTER DR. <br /> <br />Organization Name <br />SPRING LAKE PARK LIONS CLUB <br />Number of pul\1:ab and paddleticket games <br /> <br />Check if: <br /> <br />( ] this is an amended return <br />[ ] you had no gambling activity <br />[ I ScheQule B-2 <br /> <br />Number of premises <br />6 <br />City State Zip Code <br />SPRING LAKE MN 55432 <br /> <br />[ ] have you an extension to file <br />I ] this is your final return <br />[ ] Schedule F <br /> <br />reported on Schedule B.2s for the month: <br />This return includes (check): <br /> <br />Fill in number of pages below each schedule: <br /> <br />1130 <br />( 1 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 488745.00 <br />4 Add lines 1 through 3 4 488745.00 <br />5 if line 6c of iast month's Form G-1 is negative, <br /> list it in columns A and C 5 0.00 <br />6 Subtraclline 5 from line 4 6 488745.00 <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 Pulitabs 9 533610.00 <br />10 Add lines 6 through g. Line 10c is your <br /> gross profit for the month 10 1022355.00 <br />11 Multiply line 6c 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 /> 51768.00 <br /> 51768.00 <br /> 0.00 <br /> 51768.00 <br /> 0.00 <br /> 0.00 <br /> 99205.00 <br /> 150973.00 <br /> 4400.28 <br /> 571.37 <br /> 4971.65 <br /> 10154.72 <br /> 15126.37 <br /> 135846.63 <br />Date <br />g~ ...dZ-- <br />Preparer's ro number <br /> <br />0.00 <br /> <br />436977.00 <br /> <br />436977.00 <br /> <br />436977. 00 <br /> <br />0.00 <br /> <br />434405.00 <br /> <br />871382.00 <br /> <br />11 <br /> <br />12 Fill in the amount of combined receipts tax, if any (from line 9 Schedule E) <br /> <br />12 <br /> <br />13 Add lines 11 and 12, and PAY THIS AMOUNT. (Make check out to Department of Revenue) 13 <br /> <br />14 Total 1.7 percent tax paid during the month, if any (listed on distributor's invoices <br />for pulitabs and tipboards) <br /> <br />14 <br /> <br />15 Add lines 13 and 14 <br /> <br />15 <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 />16 <br /> <br />I declare that al/ information on this summa <br />Signature of chief executive officer <br /> <br /> <br />Date <br /> <br />Daytime phone <br /> <br />Preparer's signature <br /> <br />Mail this summary and tax return and attachments to <br />Minnesota Department of Revenue, Mail Station 3350. <br />6001000 (Rev: 07l99r---.~---'-'- -- _,._0._____._____ ,. - _m____._ -.--- <br /> <br />St. Paul, MN 55146-3350 <br /> <br />Minnesota-Gambler <br />