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cK� <br /> Maiaac 3eth State tottery <br /> C,onr,.m.isiioK <br /> BEANO DIVISION <br /> P.O.Box 800 <br /> Braintree,Massachusetts 02184 <br /> Tei.617-848-7755 <br /> I ROBERT O.CRANE <br /> JAMES E. HOSKER . <br /> Chairman Executive Director <br /> RAFFLE AND/OR BAZAAR TAX RETURN <br /> 4 <br /> f'. <br /> 44gg <br /> t£a:. ATTENTION: FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br /> FILE RETURN AND PAYMENT Received <br /> WITHIN 10 DAYS AFTER OCCASION IDENTIFICATION NUMBER <br /> TO ABOVE ADDRESS <br /> > (SEE PENALTIES PAGE 2—PAR.A.THROUGH E.) <br /> CHECK (V) <br /> TYPE OF ACTIVITY: RAFFLETf BAZAAR ❑ OTHER (SPECIFY) <br /> PLEASE TYPE OR PRINT IN INK -- -- — i <br /> 'P NAME OF ORGANIZATION <br /> Nl fl S R G /f �P, ,?, <br /> i <br /> STREET ADDRESS OF ORGANIZATION AREA TELEPHONE NO <br /> _I I_ CODE OF ORGANIZATION <br /> I CIkIdIA1 �, �. L l -7 �7 1 I A -7 [7L <br /> CITY OR TOWN F.ID.NO.OFORGANIZATION <br /> J I <br /> SCHEDULE 1 ZIP cODE / c} __DAN_ <br /> TE FOCCASIO _ <br /> COMPUTATION OF TAX: ✓ I^ ry �/ / �Z, � j <br /> 1. Receipts From Sales j <br /> X '. .. . .. .. . . . . .$ <br /> No.of Tickets or C st Per Ticket <br /> Chances Sold or Chance <br /> 2. Other Receipts.. . . .. . .. . ..: . . . . .... .. .. . . . .. . . . . ... ... ..$ Pte'". 7 <br /> 3. GROSS RECEIPTS(Add Lines i and 2) ... . . ... ... . $ !✓ �� OZ' <br /> 4. TAX $ 1� Z.�t X .05 . .. .. ..•.... . .. . . .. . ... .. . . .. .. .. . . ... . . .. $ <br /> Amount of Line 3 <br /> 5. Penalty and Interest(See Par. D-Page 2) . . .. .. ... . .. . . .. . . . . . .. $ 2t t- <br /> r 6. TOTAL TAX DUE(Add Lines 4 and 5) ... . .. .. . .;. .. . . . . .. . . ... . . .. .. .. ... . . ... . .. <br /> SCHEDULE 2 <br /> COMPUTATION OF NET PROFIT OR (LOSS): <br /> 1. GROSS RECEIPTS (From Line 3—Schedule 1) . .. .. . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . $ �`'Y" <br /> 2. LESS EXPENSES: _ <br /> A. Total Prizes Awarded (Cash or Value) . . . . . .. . . . .. . . . . .$ <br /> B. Other Expenses . . . . . . . . . . . . . .. . . . .. . . .. . . . . . . . . . . . .$ <br /> C. Tax Paid(Line 6—Schedule 1) . . . . . . . . .. . . .. . . . . . . . . . air 6f� <br /> I <br /> D. TOTAL EXPENSES (Add Items 2A-B-C) . . . .. .. . . . .. . . . . . .. . . . . . . .. . . . . .. . . . . . Ll j" <br /> 3. NET PROFIT OR(LOSS) (Subtract Line 2D From Line 1) . . . . . . . . . . . . . . .. . . . . . . . . . . . $ �� Z <br /> FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br /> z I' ITDATE CHECK RECEIVED DATE CHECK DEPOSITED <br /> CHECK INV, <br /> --�—� UM ER NUMBER ID <br /> MO DAY YR - MO DAY YR <br /> (OVER) <br /> 7-83-SM <br /> i`tira <br />