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<br />{r <br />v <br />MINNESOTA Depanment of Revenue <br /> <br />Monthly Lawful Gambling Activity <br />Summary and Tax Return <br /> <br />G-1 <br /> <br />Organization License Number <br />00584 <br /> <br />Number of premises <br />6 <br /> <br />Month and year reporled <br />9/2002 <br />Street (Address) <br />8433 CENTER DR. <br /> <br />Organization Name <br />SPRING LAKE PARK LIONS CLUB <br /> <br />City State <br />SPRING LAKE MN <br /> <br />Zip Code <br />55432 <br /> <br />Number of pu/ltab and paddletieket games <br /> <br />reported on Schedule 8-25 for the month: <br />This return includes (Check): <br /> <br />Fill in number of pages be/ow each schedule: <br /> <br />Check it <br /> <br />[ J this is an amended retum <br />[ ] you had no gambling activity <br />r;;(Schedule B~2 <br /> <br />I ) have you an extension to file <br />{ ] this is your final return <br />f>cJ. Schedule F <br /> <br />1029 <br />tA Schedule A <br /> <br /> Column C <br /> net receipts <br /> 0.00 <br /> 5011.00 <br /> 60844.00 <br /> 65855.00 <br /> 0.00 <br /> 65855.00 <br /> 0.00 <br /> 0.00 <br /> 98835.00 <br /> 164690.00 <br />11 5597.68 <br />12 26101.90 <br />13 31699.58 <br />14 8339.95 <br />15 40039.53 <br />16 124650.47 <br />Date <br /> ~ <br /> <br /> Column A <br /> gross receipts <br />1 Bingo 1 0.00 <br />2 Raffles (il exempt raffles were conducted, <br /> check here 0<1 and comptete Schedule ER 2 5011.00 <br />3 Paddletickets 3 444630.00 <br />4 Add lines 1 through 3 4 449641.00 <br />5 Itline 6c otlast month's Fonn G-1 is negative, <br /> list it in columns A and C 5 0.00 <br />6 Subtract line 5 from line 4 6 449641.00 <br />7 Income from interest and dividends (fill <br /> in same amount in columns A and C) 7 0.00 <br />8 Tipboards 8 0.00 <br />9 Pulltabs 9 511802.00 <br />10 Add lines 6 through g. Line 10c is your <br /> gross profit for the month 10 961443.00 <br />11 Multiply line 6c by .085 (8.5%) <br /> (itline 6c is a negative number, fill in zero here) <br /> <br />Column B <br />prizes <br /> <br />0.00 <br /> <br />0.00 <br /> <br />383786.00 <br /> <br />383786.00 <br /> <br />383786.00 <br /> <br />0.00 <br /> <br />412967.00 <br /> <br />796753.00 <br /> <br />12 Fi/J in the amount of combined' receipts tax, jf any (from line 9 Schedule E) <br /> <br />13 Add lines 11 and 12, and PA Y THIS AMOUNT. (Make check out to Department oj Revenue) <br /> <br />14 Total 1.7 percent/ax paid during Ihe month, if any (listed on distributors invoices <br />for pulltabs and tipboards) <br /> <br />15 Add lines 13 and 14 <br /> <br />16 GROSS PROFIT after state taxes (subtract line 15 from line 10c) <br />Fill in the result here and also on line 17 on the back of this form. <br /> <br /> <br /> <br />Mail this summary and tax return and attachments 10 <br />Minnesota Department of Revenue, Mail Slation 3350. SI. Paul, MN 55146-3350 <br />6001000 (Rev. 07/99) <br /> <br />Minnesota Gambler <br />