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<br />. <br /> <br /> <br />tervi{{e <br /> <br />'E.5tablWttcf /85, <br /> <br />AUG 2 1 2002. <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />~ ~"':L 00-0""_ G..Vi:, <br /> <br />Gambling Location: <br /> <br />Irl q.. Tr--~ ;I":,0,J <br />/1 D?- <br /> <br />MonthlYear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />~-i!.'-" W 1ku.-1<'J(j., CPr- <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A. <br /> <br />Net Receipts - T otallines 2c, 3c, 8c, 9c <br />(per Schedule A ifmore than one (I) site) <br /> <br />nD3 <br /> <br />B, <br /> <br />Sums oflines 22 thru 33 <br />(per Schedule A ifmore than one (I) site) <br /> <br />Sl.,!aO <br /> <br />C. <br /> <br />Line a - line b <br /> <br />2"-'-\3 <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />1. <br /> <br />Pulltab tax to distributor <br /> <br />1'6'1 <br /> <br />2. Combined receipts tax for this site <br /> <br />3. Federal Taxes (per schedule CID) <br /> <br />4. <br /> <br />State Gambling Tax (per line 11) <br /> <br />3 <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />I'lL... <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />HS\ <br />IUp <br /> <br />E. <br /> <br />Line c - line d <br /> <br />40% <br /> <br />5'bD List Receivers of funds/or attach a <br />separate page <br /> <br />Signature: <br /> <br /> <br />\l..\l,o PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />~()JJ;\ <br />'J \ . ) <br /> <br />10% <br />