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<br />. <br /> <br /> <br />'Establi.-,.iiet{ Ui.t:I; <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />l)vo 't:nDK-11.. ..s...c"",~ c,- \..6 <br /> <br />Gambling Location: <br /> <br />W::;::Sii.- b;v'-1 '0 P:;:'-'->A <br />, <br /> <br />MonthlYear: <br /> <br />-110'1.- <br />I <br /> <br />Name ofIndividual Completing Form: <br /> <br />~A-jJf w ~u..~ . C.?!A <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 (1) site) <br /> <br />391'-1 <br /> <br />B. <br /> <br />Sums oflines 22 thru 33 <br />(per Schedule A if more than one (I) site) <br /> <br />'2-~")C; <br />_________-..J <br /> <br />C. <br /> <br />Line a - line b <br /> <br />L1'l9 <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />I. <br /> <br />Pulltab tax to distributor <br /> <br />YOlo <br /> <br />2. Combined receipts tax for this site <br /> <br />3. Federal Taxes (per schedule CID) <br /> <br />4. State Gambling Tax (per line II) <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />YDlo <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />Y3 <br />'2.-\ <br /> <br />E. <br /> <br />Line c - line d <br /> <br />40% <br /> <br />n <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />10% <br /> <br />y <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: <br /> <br />~ ~' <br />'~--I;J' \L.1Li <br />