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Wasjachusettj State oLottery (fommission . <br /> BEANO DIVISION <br /> P.O.Box 800 " <br /> Braintree,Massachusetts02184 n e� <br /> Tel.617-848-7755 <br /> T Q.CRANE DR.WILLIAM E.PERRAULT <br /> ROBER Executive Director <br /> Chairman <br /> RAFFLE AND/OR BAZAAR TAX RETURN <br /> TTENTION: FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br /> Received <br /> ILE RETURN AND PAYMENT IDENTIFICATION NUMBER <br /> ITHIN 10 DAYS AFTER OCCASION <br /> OABOVE ADDRESS <br /> SEEPENALTIES PAGE 2—PAR.A.THROUGH E.) <br /> HECK(V) <br /> PE OF ACTIVITY: RAFFLED BAZAAR ❑ OTHER (SPECIFY) — <br /> EASE TYPE OR PRINT IN INK <br /> NAME OF ORGANIZATION <br /> MA Is 11+1 P1 d g-1 I Cc Mr4L�- tic / IY sc1- 0 © 4 <br /> __ AREA TELEPHONE NO <br /> STREET ADDRESS OF ORGANIZATION CODE OF ORGANIZATION <br /> TA til s <br /> _ GITY �RTOwNF.ID.NO.OF ORGANIZATION <br /> I- j S <br /> TE <br /> ZIP CODE _ _ DATE OF OCCASION <br /> SCHEDULE 1 <br /> COMPUTATION OF TAX: — <br /> 1. Receipts From Sales <br /> U L7. <br /> . ....... . . . . . . .� SZ� <br /> No.of Tickets or Cost Per Ticket <br /> Chances Sold or Chance <br /> 2. Other Receipts. . . . . . . . . . . . . . . . . . . . . . . . .. ....... . . .. . ... .$ v l — <br /> /�. <br /> 3. GROSS RECEIPTS (Add Lines 1 and 2) $ <br /> 4. TAX SJAI -71 S X .05 . . .. . . . . . . . . ... . .. . ... . . . .. . . .. .. . .. . . . . . . ..... <br /> Amount of Line 3 <br /> 5. Penalty and Interest (See Par. D-Page 2) ... . . ... ........ . ... . .. . . . ...... . ........ $ <br /> $ $ / <br /> 6. TOTAL TAX DUE (Add Lines 4 and 5) . ' ' •'''' ' ' ' • ' ' ' <br /> SCHEDULE 2 <br /> COMPUTATION OF NET PROFIT OR (LOSS): �1 `7, S� <br /> 1. GROSS RECEIPTS (From Line 3—Schedule 1) .... . ... . . ..... . . . ........ . . • . . . $ <br /> i <br /> 2. LESS EXPENSES: j <br /> A. Total Prizes Awarded (Cash or Value) ' <br /> B. Other Expenses . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . .. . . . . <br /> C. Tax Paid (Line 6—Schedule 1) . .. . . . . .. . . ...... . .. . . . 3 <br /> D. TOTAL EXPENSES (Add Items 2A-B-C) . . . . ... ..... . . . . .. .. . . . . ..... . . .• • • ••• $ <br /> , 5,-"C , y <br /> 3. NET PROFIT OR (LOSS) (Subtract Line 2D From Line 1) . .. . . . .. . . . . . ..• • •• •• • . $ <br /> I <br /> DATE CHECK RECEIVED FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY DATE CHECK DEPOSITED <br /> IIS"- CHECK NUINV <br /> MBER�❑ m �YR❑ <br /> m DAY <br /> R MO <br /> IOM NUMBE <br /> DAY YR (OVER) <br />