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MINNESOTA DEPARTMENT OF REVENUE LAWFUL GAMBLING ACTIVITY SUMMARY and TAX RETURN <br /> Mail Station 3350 <br /> St.Paul, MN 55146 - 3350 License: 03800 Month: MAY 1999 <br /> Premises: 3 Schedule 82 GAME COUNT: 74 <br /> Organization Name: Address: <br /> Dead Broke Saddle Club 19680 Harrow Avenue North, Forest Lake MN 55025 <br /> Attached: Schedule A: 3, Schedule B2: 6, 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 690.00 667.00 23.00 <br /> 4 Income from Interest and Dividends 77.96 - -- 77.96 <br /> 5 SUB -TOTAL (Add Lines 1 through 4) 767.96 667.00 100.96 <br /> 6 Last Month Line 7C, if it was negative . . 0.00 - -- 0.00 <br /> 7 Adjusted Sub -Total (Line 5 minus Line 6) . 767.96 667.00 100.96 <br /> 8 Tipboards 0.00 0.00 0.00 <br /> 9 Pulltabs 163,554.50 133,604.00 29,950.50 <br /> 10 TOTALS (Add Lines 7,8,9) 164,322.46 134,271.00 30,051.46 <br /> 11 Gambling Tax (9.5% of Line 7C) 9.59 <br /> 12 Combined Receipts Tax (Schedule E, Line 9) 9,327.05 <br /> 13 PAY THIS AMOUNT (Line 11 plus Line 12) Check to Department of Revenue: 9,336.64 <br /> 14 Gambling Tax Paid to Distributors for Pulltabs & Tipboards 5,305.16 <br /> 15 TOTAL Gambling Tax (Add Lines 13 and 14) 14,641.80 <br /> 16 GROSS PROFIT, After Taxes (Line 10C minus Line 15) 15,409.66 <br /> 17 15,409.66 <br /> 18 Beginning Inventory (Last Month Line 21) . . 3,264.40 <br /> 19 Gambling Product Obtained, with Sales Tax. . 3,686.01 <br /> 20 Goods Available (Line 18 plus Line 19) . . . 6,950.41 <br /> 21 Ending Inventory (excludes Sales Tax). . . . 4,263.86 <br /> 22 Goods Used (Line 20 minus Line 21) 2,686.55 <br /> 23 Compensation and Payroll taxes 10,007.94 <br /> 24 Penalty or Interest on Taxes paid during the month . . . 0.00 <br /> 25 Advertising 0.00 <br /> 26 Accounting and Legal Services 250.00 <br /> 27 Miscellaneous Expenses, Supplies & Bank Charges 0.00 <br /> 28 Purchase /Repair of Furnishings or Devices for Gambling . 106.59 <br /> 29 Rent for the Purpose of Conducting Lawful Gambling . . . 2,350.00 <br /> 30 Utilities 0.00 <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( +) 144.00 <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) 15,545.08 <br /> 37 NET PROFIT (Line 17 minus Line 36) - 135.42 <br /> 38 Prior Month Profit Carry -Over (Line 44 from Last Month) 52,990.69 <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) 52,855.27 <br /> 41 Lawful Purpose Expenditures (Line 11 Schedule C /D) . . . . 334.00 <br /> 42 Board - Approved Expenditures (Line 13 Schedule C /0) . . . . 0.00 <br /> 43 Total Expenditures (Add Lines 41 and 42) 334.00 <br /> 44 PROFIT CARRY -OVER (Line 40 minus Line 43) 52,521.27 <br /> 46 FUNDS BALANCE DIFFERENCE from Schedule F, Line 22 0.00 <br /> 47 Pulltab & Tipboard UNSOLD TICKETs this month 44.062.00 <br /> I declare that all information on this summary and return is true, correct and complete. <br /> Chief Execute 4! / Date Gambling / Date <br /> Office jP/ t 7 4 Mana erl <br /> Prep. et :y Date 612/464 -7225 <br /> J,64c. Ht . 4c444 c Pa 6 /zo111 <br />