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<br /> <br />tervi{{e <br /> <br />'uta6/L<lie,( 1857 <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />Organization Name: ~~ V':n.~ ~Cl,'" CLv6 <br /> <br />Gambling Location: <br /> <br />W::r:SR.. SV"l" P:i:""-'" <br />, <br /> <br />110'1.- <br />I <br /> <br />MonthlYear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />'CfU..vT W ~u..~ c.f,." <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 (1) site) <br /> <br />39/'-I <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (I) site) <br /> <br />",c:~c:- <br />__t......J <br /> <br />C. <br /> <br />Line a - line b <br /> <br />L.H9 <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />I. <br /> <br />Pulltab tax to distributor <br /> <br />YOG <br /> <br />2. Combined receipts tax for this site <br /> <br />3. Federal Taxes (per schedule C/D) <br /> <br />4. State Gambling Tax (per line 11) <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />YD\':' <br /> <br />E. <br /> <br />Line c - line d <br /> <br />"""'7 <br />I~ <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />?-.\ <br /> <br />40% <br /> <br />n <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />10% <br /> <br />L-\ <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />Signature: <br /> <br />~~;l 'l1I] <br />