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� /n1 //�� <br /> V433achwdb Slat, oC lb y (-.ommimion ---_ <br /> yd <br /> CHARITABLE GAMING DIVISION <br /> P.U. Box 800 . <br /> Braintree, Massachusetts 02184 <br /> Tel.617-849-5555 <br /> ROBERT O.CRANE `/ JAMES E. HOSKER <br /> Chairman Executive Director <br /> RAFFLE AND/OR BAZAAR TAX RETURN <br /> 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(, ) <br /> TYPE OF ACTIVITY: RAFFLE BAZAAR ❑ OTHER (SPECIFY) Q <br /> PLEASE TYPE OR PRINT IN INK <br /> NAME OF ORGANIZATION <br /> ire I 1 6- 1 1 G O /V N r- C: Z u a ;N�. <br /> STREET ADDRESS OF ORGANIZATION AREA TELEPHONE NO <br /> CODE OF ORGANIZATION <br /> ' I Y1-7]-716 <br /> CITY OR TOWN F.ID.NO OF ORGANIZATION <br /> Mr <br /> 0 1 '� /' 7 ,)/ 3 A.( <br /> SCHEDULE 1 ZIP CODE DATE OF OCCASION <br /> COMPUTATION OF TAX: Lo 1 7- <br /> 1. Receipts From Sales <br /> No. of Tickets or Cost Per Ticket <br /> Chances Sold or Chance <br /> 2. Other Receipts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S <br /> 3. GROSS RECEI�,PT/J (Add Lines 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ <br /> 4. TAX $ ��`. 1 00 X .05 . . . . . . . $ <br /> Amount of Line 3 <br /> 5. Penalty and Interest (See Par. D-Page 2) . . . . . . . . . . . . . . . $ <br /> 6. TOTAL TAX DUE (Add Lines 4 and 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ <br /> ZSCHEDULE 2 <br /> Z COMPUTATION OF NET PROFIT OR (LOSS): <br /> 0 1. GROSS RECEIPTS (From Line 3—Schedule 1) . . . . S <br /> i <br /> } 2. LESS EXPENSES: <br /> a .. <br /> A. Total Prizes Awarded (Cash or Value) . . . . . . . . . . . . . . . ... 171V �•00 ' <br /> B. Other Expenses . . . . . . . <br /> C. Tax Paid (Line 6—Schedule 1) . . . . . . . . . . . . . . . . . . . . . . .$ �2 <br /> D. TOTAL EXPENSES (Add Items 2A-B-C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ �`� 'o0 <br /> 3. NET PROFIT OR LOSS Subtract Line 2D From Line 1 ar���o •��� <br /> DATE CHECK RECEIVED FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br /> DATE CHECK DEPOSITED <br /> 0 <br /> ❑� UCHECK <br /> MBER -T-1 NUIN V <br /> MBER m ❑� �❑ ❑� <br /> DAY YR MO DAY YR <br /> (OVER) <br />