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<br /> MINNESOTA DEPARTMENT OF REVENUE LAWFUL GAMBLING ACTIVITY SUMMARY and TAX RETURN
<br /> `Mail Station 3350
<br /> St.Paul, MN 55146 - 3350 License: 03800 Month: JANUARY 1999
<br /> Premises: 3 Schedule 82 GAME COUNT: 56
<br /> irganization Name: Address:
<br /> lead Broke Saddle Club 19680 Harrow Avenue North, Forest Lake MN 55025
<br /> Attached: Schedule A: 3, Schedule B2: 5, Schedule E: 1, Schedule F: 1
<br /> (A) Gross (8) Prizes (C) Net
<br /> 1 Bingo 0.00 0.00 0.00
<br /> 2 Raffles 0.00 0.00 0.00
<br /> 3 Paddletickets 450.00 435.00 15.00
<br /> 4 Income from Interest and Dividends 95.66 - -- 95.66
<br /> 5 SUB -TOTAL (Add Lines 1 through 4) 545.66 435.00 110.66
<br /> 6 Last Month Line 7C, if it was negative . . 0.00 - -- 0.00
<br /> 7 Adjusted Sub -Total (Line 5 minus Line 6) . 545.66 435.00 110.66
<br /> 8 Tipboards 0.00 0.00 0.00
<br /> 9 Pulltabs 125,914.50 102,472.00 23,442.50
<br /> 10 TOTALS (Add Lines 7,8,9) 126,460.16 102,907.00 23,553.16
<br /> 11 Gambling Tax (9.5% of Line 7C) 10.51
<br /> 12 Combined Receipts Tax (Schedule E, Line 9) 7,182.58
<br /> 13 PAY THIS AMOUNT (Line 11 plus Line 12) Check to Department of Revenue: 7,193.09
<br /> 14 Gambling Tax Paid to Distributors for Pulltabs & Tipboards 3,504.85
<br /> 15 TOTAL Gambling Tax (Add Lines 13 and 14) 10,697.94
<br /> 16 GROSS PROFIT, After Taxes (Line 10C minus Line 15) 12,855.22
<br /> 17 12,855.22
<br /> 18 Beginning Inventory (Last Month Line 21) . . 2,972.74
<br /> 19 Gambling Product Obtained, with Sales Tax. . 2,728.88
<br /> 20 Goods Available (Line 18 plus Line 19) . . . 5,701.62
<br /> 21 Ending Inventory (excludes Sales Tax). . . . 3,621.62
<br /> 22 Goods Used (Line 20 minus Line 21) 2,080.00
<br /> 23 Compensation and Payroll taxes 10,397.35
<br /> 24 Penalty or Interest on Taxes paid during the month . . . 0.00
<br /> 25 Advertising 0.00
<br /> 26 Accounting and Legal Services 683.00
<br /> 27 Miscellaneous Expenses, Supplies & Bank Charges 809.35
<br /> 28 Purchase /Repair of Furnishings or Devices for Gambling . 2,254.25
<br /> 29 Rent for the Purpose of Conducting Lawful Gambling . . . 2,300.00
<br /> 30 Utilities 200.00
<br /> 31 Theft and Liability Insurance 0.00
<br /> 32 Manager's Bond, Licenses, Local Fee, Premises Permit . . 0.00
<br /> 33 Cash Long( -) or Cash Short( +) -72.50
<br /> 34 DEPOSIT REQUIRED, Excess Cash Short Reimbursement( -) . . 0.00
<br /> 35 Deposited Amount, Excess Expense Reimbursement( -) 0.00
<br /> 36 TOTAL ALLOWABLE EXPENSES (Add Lines 22 through 35) 18,651.45
<br /> 37 NET PROFIT (Line 17 minus Line 36) - 5,796.23
<br /> 38 Prior Month Profit Carry -Over (Line 44 from Last Month) 43,195.28
<br /> 39 Approved Adjustments (Attach Letter and /or Add Line 6C if not zero). . 0.00
<br /> 40 BALANCE Sub -Total (Add Lines 37, 38 and 39) 37,399.05
<br /> 41 Lawful Purpose Expenditures (Line 11 Schedule C /D) . . . . 182.00
<br /> 42 Board - Approved Expenditures (Line 13 Schedule C /D) . . . . 0.00
<br /> 43 Total Expenditures (Add Lines 41 and 42) 182.00
<br /> 44 PROFIT CARRY -OVER (Line 40 minus Line 43) 37,217.05
<br /> 46 FUNDS BALANCE DIFFERENCE from Schedule F, Line 22 0.00
<br /> 47 Pulitab & Tipboard UNSOLD TICKETs this month 20,703.00
<br /> I declare that all inform ion on this summary and return is true, correct and complete.
<br /> Chief rxecutiv ` (ll ,. D e Gambling Date
<br /> Officer: ) /9 -`I`I Ma in i
<br /> Prepared By Date 612/464 -7225
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