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<br /> <br />tervi[[e <br /> <br />'.f..itabfi..JleJ"J8...l:ji <br /> <br />CITY OF CENTERVILLE <br />Monthly Gambling Summary <br /> <br />Organization Name: _\)t;,1-D 0-,/>'1 "ILl'. S",.oOVL (~v'.6 <br /> <br />Gambling Location: <br /> <br />!iJr:Si GUY) rn,,1I <br />q ! ()~ <br /> <br />MonthlYear: <br /> <br />Name ofIndividual Completing Form: <br /> <br />17 'J r, ,.... 1. <br />[~(Z:!:{J--r' I,Cr',I...t.__/"'(.,.., '~_,('7''''' <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 />Y-!YL <br /> <br />B. <br /> <br />S urns 0 flines 22 thru 33 <br />(per Schedule A ifmore than one (1) site) <br /> <br />LS,q;!", <br /> <br />c. <br /> <br />Line a - line b <br /> <br />C::-~I <br />-'~IO <br /> <br />Miscellaneous Deductions (for this site only) <br /> <br />1. <br /> <br />Pulltab tax to distributor <br /> <br />2\\ <br /> <br />2. <br /> <br />Combined receipts tax for this site <br /> <br />~'b3 <br /> <br />3. Federal Taxes (per schedule CID) <br /> <br />4. <br /> <br />State Gambling Tax (per line 11) <br /> <br />4 <br />I..- <br /> <br />D. <br /> <br />Total Miscellaneous Deductions for this site <br /> <br />tog \p <br /> <br />F. <br /> <br />Line e X 50% <br /> <br />AMOUNT DUE <br /> <br /><\'10 ') <br />\'lo) <br /> <br />E. <br /> <br />Line c - line d <br /> <br />40% <br /> <br />, <br />< 5\",) <br /> <br />List Receivers of funds/or attach a <br />separate page <br /> <br />(1"-\) <br /> <br />10% <br /> <br />PAY ABLE TO THE CITY OF <br />CENTERVILLE *DUE ANNUALLY <br />AS PER ORDINANCE* <br />//L .- ,(J I" <br />\ p' ) il A. I) /'. <br />, V,- 'j;' Iv--- \ <br />f-' \ <br />.;- , <br />) <br />, <br /> <br />. <br /> <br />Signature: <br />