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<br />, <br /> <br /> <br />tervi[[e <br /> <br />'Esta6fislid 1115; <br /> <br />AUG 2 1 2002. <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />W-/n) ~"'([ S0-OtM'_ G..v~ <br /> <br />Gambling Location: <br /> <br />11'1 i'1-- T(l--:::;) ::;::,u,) <br />/1 D?.- <br /> <br />MonthlYear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />"k-l!.u;- W \kLJ..."'~(j., CP,k <br /> <br />Ten Percent Net Profit Calculation <br /> <br />A. <br /> <br />Net Receipts - T otallines 2c, 3c, 8c, 9c <br />(per Schedule A if more than one (I) site) <br /> <br />no3 <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A ifmore than one (I) site) <br /> <br />51..1,,0 <br /> <br />c. <br /> <br />Line a - line b <br /> <br />:z-z..'-\~ <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />1. <br /> <br />Pulltab tax to distributor <br /> <br />i'b'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 />-z. <br />~ <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />1'1"'2- <br />\L.-\S\ <br /> <br />iUp <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />E. <br /> <br />Line c - line d <br /> <br />40% <br /> <br />5'bD List Receivers offundslor attach a <br />separate page <br /> <br />Signature: <br /> <br /> <br />\l.\t,., PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />if\Uil~ <br /> <br />10% <br />