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<br />MONTHLY SUMMARY and TAX RETURN (&-1) <br />lawful Gambling Activity <br /> <br />Month and Year Premises <br />OCTOBER 2002 4 <br />Address <br />19680 Harrow Avenue North. Forest lake MN 55025 <br />Attached: Schedule A Schedule 82 Schedule F <br />4 13 1 <br /> <br />(A) Gross (B) Prizes (e) Net <br />1 0.00 0.00 0.00 <br /> <br />MINNESOTA DEPARTMENT OF REVENUE <br /> <br />Irganization License <br />03800 <br />Name <br />Dead Broke Saddle Club <br />Schedule B-2 Game Count <br />155 <br /> <br />1 Bingo. . <br /> <br />2 Raffles ( ] Exempt, Schedule-ER <br />3 Paddletickets. . . . <br /> <br />2 0.00 <br />3 2,130.00 <br />4 2,130.00 <br />5 0.00 <br />6 2,130.00 <br />7 40.41 <br />8 0.00 <br />9 235,100.50 <br />.10 237,270.91 <br /> <br />4 SUB-TOTAL (Add Lines 1 through 3). <br /> <br />5 Last Month Line 6C, if it was negative <br />6 Adjusted Sub-Total (Line 4 minus Line 5) <br /> <br />7 Income from Interest and Dividends <br /> <br />8 Tipboards. <br />9 Pulltabs . <br /> <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 />0.00 <br />2,059.00 <br />2,059.00 <br /> <br />2,059.00 <br /> <br />0.00 <br /> <br />193,821. 00 <br />195,880.00 <br /> <br />13 PAY THIS AMOUNT (Line 11 plus Line 12) Check to Department of Revenue. 13 <br /> <br />14 Gambling Tax Paid to Distributors for Pulltabs & Tipboards <br /> <br />15 TOTAL Gambling Tax (Add Lines 13 and 14) . . . <br /> <br />0.00 <br />71. 00 <br />71.00 <br />0.00 <br />71. 00 <br />40.41 <br />0.00 <br />41,279.50 <br />41,390.91 <br /> <br />11 <br />12 <br /> <br />6.04 <br />9,359.39 <br />9,365.43 <br />4,620.86 <br /> <br />14 <br /> <br />15 13,986.29 <br /> <br />16 GROSS PROFIT, After Taxes (Line 10C minus Line 15) to line 17, page 2. 16 27,404.62 <br /> <br /> <br />orrect and co lete. <br />r Date. <br />~~ ;/r-C;?,,- <br />Pre parer 10 number <br />I u <br /> <br /> <br />and return is true <br />Signature <br />-0 ~ Gamb 1 in Mr. <br />Phone <br />. ,.... 0'1...- ':;'"1-'1~ <br />ation 3350, StPaul, MN 55416-3350 <br /> <br />I declare t at all <br />Signature <br />Chief Exec. <br />Signature <br />Pre arer <br />Mail to: MN D <br />