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<br /> <br />tervi{{e <br /> <br />'uta6fL"i,,{ /857 <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />l"--. - . <'. '\2." r ~""" n r'" .., <br />~.l-i ,.--\V\Jlr<.rt ~-l.iC'-~1~ \..,L..V\.:) <br /> <br />J~ ;~ <br />",,,L <br /> <br />2 0 <br /> <br />?r.t;;) <br />,b~,,'.:I:!~ <br /> <br />Gambling Location: <br /> <br />"'--!'i{. I"~:;:o 1-. \J,J <br /> <br />MonthlY ear: <br /> <br />lot o-z.,.... <br /> <br />Name ofIndividual Completing FOrni: <br /> <br />'\2,rz<1.J..>,\ w Il 'u.;'"''-'''6' ,~Cl "- <br />---1:::::: '.J ,,-----,.r\ <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 />1,--\19\0 <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A ifmore than one (1) site) <br /> <br />s\L.-1S <br /> <br />c. <br /> <br />Line a - line b <br /> <br />7..-:;2--\ <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />L <br /> <br />Pulltab tax to distnbutor <br /> <br />\'-\\1 <br /> <br />2. <br /> <br />Combined receipts tax for this site <br /> <br />L..y , D <br /> <br />3. Federal Taxes (per schedule C/O) <br /> <br />4. <br /> <br />State Gambling Tax (per line 11) <br /> <br />y <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />2; ~o,. \ <br />< \S-1'O '; <br /><1';;5/ <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 /><(.,?-~I <br /> <br />List Receivers offimds/or attach a <br />separate page <br /> <br />10% <br /> <br />\\SI/ <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />S R ORDINANCE* <br /> <br />Signature: <br /> <br /> <br />~.- <br />