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<br /> <br />ter'lli[[e <br /> <br />'Estafj{isliuf 1857 <br /> <br />Organization Name: <br /> <br />Gambling Location: <br /> <br />MonthlYear: <br /> <br />nit";.'] 01 ;<, <br />_\V'~j '~7 '}l'lf1~) <br />1;.!I!!a; <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br />/' 1 f?1 <br />~I(")lr~ df~.p \o-Ir s't"JU(: <br />I <br />h!!f r;,,,,,,...r <br /> <br />~~jO~J.uJY!<"Y <br />/ <br /> <br />cJ~ <br /> <br />/12..--, I:,,(l~ <br /> <br />Na:ne ofIildividual Completing Form: <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 (1) site) <br /> <br />,-7&::2 'S .ClO <br /> <br />B. <br /> <br />Sums of lines 22 thru 33 <br />(per Schedule A if more than one (1) site) <br /> <br />t.f , '1 g.OO <br /> <br />C. <br /> <br />Line a - line b <br /> <br />Iod5.60 <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />1. <br /> <br />2. <br /> <br />Pulitab tax to distributor <br /> <br />5Q;2.00 <br />177~. 00 <br /> <br />Combined receipts tax for this site <br /> <br />3. Federal Taxes (per schedule CID) <br /> <br />4. State G=b.li.....g Tax (per!ine 11) <br /> <br />D. <br /> <br />23(,7. d7J <br /><J7<f-;l..ou/ <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />E. <br /> <br />Line c - line d <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br />-< ir7/, dO"? <br /> <br />40% <br /> <br />10% <br /> <br />Signature: <br /> <br />CD List Receivers offundslor attach a <br />separate page <br /> <br />C!:J PAYABLE TO THE CITY OF <br />CENTERVILLE *nUEANNUALLY <br />AS PER ORDINANCE* <br /> <br />f)~ t:e-1j~ <br />