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Na-mackt-jeth Nate C.Qtery (,ommimion <br /> BEANO DIVISION <br /> P.O.Box 800 <br /> Braintree,Massachusetts 02184 n <br /> Tel.617-848-7755 a,,,,o ,. <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.) t <br /> CHECK(V) <br /> TYPE OF ACTIVITY: RAFFLEIE/BAZAAR ❑ OTHER (SPECIFY) <br /> PLEASE TYPE OR PRINT IN INK <br /> NAME OF ORGANIZATION <br /> IsfffW � Au 1SIC1910101LI <br /> STREET ADDRESS OF ORGANIZATION AREA TELEPHONE NO. <br /> CODE OF ORGANIZATION <br /> CITY OR TOWN F.ID,No.OF ORGANIZATION <br /> SCHEDULE 1 <br /> ZIP CODE DATE OF OCCASION <br /> COMPUTATION OF TAX: <br /> 1. Receipts From Sales <br /> /63 X ,So $ SLl) <br /> No.of Tickets or Cost Per Ticket <br /> Chances Sold or Chance <br /> 2. Other Receipts. .. . .. . .. ... ... . .. .. ............. ... ......$ p <br /> 3. GROSS RECEIPTS (Add Lines 1 and 2) . . ............... ....... ... .. ... .......... $ <br /> C3 . SL7 <br /> 4. TAX $ 8�SO X .05 ... ....... ................ ............... ...... $ �4. o e <br /> Amount of Line 3 <br /> 5. Penalty and Interest See Par. D-Pa e 2 $ 0 - <br /> 6. TOTAL TAX DUE (Add Lines 4 and 5) ............................................ <br /> 1 SCHEDULE 2 <br /> COMPUTATION OF NET PROFIT OR (LOSS): Q <br /> 3 1. GROSS RECEIPTS (From Line 3—Schedule 1) .......... ......................... $ <br /> 2. LESS EXPENSES: <br /> o00 <br /> A. Total Prizes Awarded(Cash or Value) ................. <br /> m� B. Other Expenses 9,0 <br /> i <br /> k C. Tax Paid (Line 6—Schedule 1) .. .....................$ D 8 <br /> u; D. TOTAL EXPENSES (Add Items 2A-B-C) $ �'�/+r7- <br /> Wq .�FCY. $ <br /> 3. NET PROFIT OR LOSS Subtract Line 2D Fromrom L Linee .... .. .... .. .. <br /> 1 .. <br /> DATE CHECK RECEIVED FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br /> DATE CHECK DEPOSITED <br /> ❑� ❑� UCHECK INV. <br /> MBER I I 1 11 1. NUMBER�❑ �--✓t—J �❑ <br /> DAY YR Mo DAY YR <br /> (OVER) <br />