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<br /> <br />tervi{{e <br /> <br />'f...)tdliiL)fi~,( [851 <br /> <br />Organization Name: <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />-.1)~ i3rt~~ s'4D;ul. C\~,,~ <br /> <br />Gambling Location: <br /> <br />1rt.1..-, r^J,J <br />}D 10L.- <br /> <br />MonthlYear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />b14.1J1 It-J "\l,SUJ:NC, (~PA- <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 (l) site) <br /> <br />1<1110 <br /> <br />B. <br /> <br />S urns 0 f lines 22 thru 33 <br />(per Schedule A if more than one (1) site) <br /> <br />511 :J <br /> <br />C. <br /> <br />Line a - line b <br /> <br />19'1 \ <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />I . Pulltab tax to distributor 57..'1 <br /> <br /> <br />2. Combined receipts tax for this site -.J 19 'l <br /> <br />3. Federal Taxes (per schedule CID) <br /> <br />4. <br /> <br />State Gambling T ax (per line 11) <br /> <br />5 <br /> <br />F. <br /> <br />Line eX 50% <br /> <br />AMOUNT DUE <br /> <br />1-:,1-1 <br /><: ")CbY / <br />(\91,7 <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 />(\1>1) <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />(\~) <br /> <br />10% <br /> <br />PAYABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br /> <br />~~\J\Wl \ <br />. - \ <br /> <br />Signature: <br />