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Mamal teeth State c otter y C,ommimion <br /> BEANO DIVISION <br /> P.O.Box 800 lug <br /> Braintree,Massachusetts 02184 <br /> Tel.617-848-7755 �; ,�6,lT,n <br /> .& <br /> `7 CRANE DR.WILLIAM E.PERRAULT <br /> ROBERT O. <br /> Chairman Executive Director <br /> RAFFLE AND/OR BAZAAR TAX RETURN <br /> ATTER N: FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br /> Received <br /> FILE RETURN AND PAYMENT IDENTIFICATION NUMBER <br /> WITHIN 10 DAYS AFTER OCCASION <br /> TO ABOVE ADDRESS <br /> (SEE PENALTIES PAGE 2—PAR.A.THROUGH E.) <br /> CHECK(V) �,( <br /> TYPE OF ACTIVITY: RAFFLE LJ BAZAAR ❑ OTHER (SPECIFY) <br /> PLEASE TYPE OR PRINT IN INK <br /> NAME OF ORGANIZATION <br /> 1511+1 A I d " 111 t ic1 1 y <br /> AREA TELEPHONE NO. <br /> STREET ADDRESS OF ORGANIZATION CODE OF ORGANIZATION <br /> CITY OR TOWN F.ID.NO.OFORGANIZATION <br /> h4T,4s hi I cFrUAA I s s t4C4 a C, T <br /> I <br /> ZIP CODE DATE OF OCCASION <br /> SCHEDULE 1 Q � , 11 -/5-gam <br /> COMPUTATION OF TAX: <br /> 1. Receipts From Sales <br /> 3 5- X ........... ......$ <br /> No.of Tickets or Cost Per Ticket <br /> Chances Sold or Chance J'} <br /> 2. Other Receipts. .. . . .. .. . .. . ...... .... .. ....... <br /> 3. GROSS RECEIPTS (Add Lines 1 and 2) .. ... ... ... $ <br /> 5' <br /> 4. TAX $ ��Jif�� X .05 ........ . ........ ......... ........ .... ... ..... . $ <br /> Amount of Line 3 <br /> M <br /> 5. Penalty and Interest(See Par. D-Page 2) . ...... . ................... ............... $ <br /> $ <br /> 6. TOTAL TAX DUE(Add Lines 4 and 5) .........••••• • . <br /> �, S <br /> S_ CHEDULE 2 b <br /> COMPUTATION OF NET PROFIT OR (LOSS): <br /> 3 r .1. GROSS RECEIPTS (From Line 3—Schedule 1) .. .. . ..... ..••••• •••••••••••' <br /> 2. LESS EXPENSES: p / <br /> lDI <br /> A. Total Prizes Awarded(Cash or Value) . . .............. . .� 1 <br /> " B. Other Expenses . ... . . . . ........ .... .......... ..... .$ <br /> 17 <br /> n C. Tax Paid (Line 6—Schedule 1) / �+ S3 <br /> D. TOTAL EXPENSES (Add Items 2A-B-C) ............ . .... 93 <br /> ivv p <br /> 3. NET PROFIT OR(LOSS) (Subtract Line 2D From Line 1) .. .. •.•.••• ••••••• • $ 7 j <br /> FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY DATE CHECK DEPOSITED <br /> DATE CHECK RECEIVED m <br /> I I7 FTI 1 7_1 ;❑ INV. EE <br /> CHECK NUMBER <br /> NUMBER <br />