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<br />, <br /> <br />MINNESOTA DEPARTMENT OF REVENUE <br /> <br />MONTHLY SUMMARY and TAX RETURN (G-l) <br />lawful Gambling Activity <br /> <br />Month and Year Premises <br />JULY 2002 5 <br />Address <br />19680 Harrow Avenue North. Forest lake MN 55025 <br />Attached: Schedule A Schedule B2 Schedule F <br />5 10 1 <br /> <br />(A) Gross (B) Prizes (C) Net <br />1 0.00 0.00 0.00 <br /> <br />Organization License <br />03800 <br />Name <br />Dead Broke Saddle Club <br />Schedule B-2 Game Count <br />124 <br /> <br />I Bingo. <br /> <br />. .. ...... <br /> <br />2 Raffles [ J Exempt, Schedule-ER <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 /> <br />6 Adjusted Sub-Total (Line 4 minus Line 5) 6 <br /> <br />7 Income from Interest and Dividends <br /> <br />7 <br />8 <br />9 <br />.10 <br /> <br />8 Tipboards. <br /> <br />9 Pulltabs . <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 />2 <br />3 <br />4 <br />5 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />1,102.00 <br />1,102.00 <br /> <br />1,102.00 <br /> <br />0.00 <br />201,603.00 <br />202,705.00 <br /> <br />0.00 <br />38.00 <br />38.00 <br />0.00 <br />38.00 <br />29.49 <br />0.00 <br />49,054.00 <br />49,121.49 <br /> <br />11 <br />12 <br /> <br />3.23 <br />0.00 <br /> <br />1,140.00 <br /> <br />1,140.00 <br />0.00 <br />1,140.00 <br />29.49 <br />0.00 <br />250,657.00 <br />251,826.49 <br /> <br />13 PAY THIS AMOUNT (Line 11 plus Line 12) Check to Department of Revenue. 13 3.23 <br /> <br />14 Gambling Tax Paid to Distributors for Pulltabs & Tipboards <br /> <br />15 TOTAL Gambling Tax (Add Lines 13 and 14) . . . . . <br /> <br />14 <br />15 <br /> <br />4,967.93 <br />4,971.16 <br /> <br />16 GROSS PROFIT, After Taxes (Line 10C minus Line 15) to line 17, page 2. 16 44,150.33 <br /> <br /> <br />inforlation on this summar and return is true <br />Date Signature <br />r-9-C>Z- Gamblin Mr. <br />\ Da,te Phone <br />,11,...lo-t_ \fit 11;1'-'"\10< <br />Mail:S ation 3350, StPaul, MN 55416-3350 <br /> <br />declare that al <br />Signature <br />hief Exec. <br />Signature <br />Pre arer <br />Mail to: MN Dep .of Revenue, <br /> <br />