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sctc� tt� <br /> gFsc,IN'aEE A„SACHUSET'SOi <br /> TEL 8;7-64E-775' <br /> CASINO FUNCTION FINANCIAL RETURN" <br /> ROBERT O. CRANE <br /> EXECUTIVE DIRECTOR <br /> Chairman <br /> ATTENTIQ_N-. FILE COMPLETED RETURN S ALT IN SUSPENSION GPF10 DA_YSkFfE__{JREVOGAT ON E PERMIT. <br /> ADDRESS. <br /> FAILURE TO cotA LY WILL RE <br /> ORGANIZATION –�� I_L�_ <br /> '`� <br /> NAME OF ORGANIZATION ,t ) ,{ IDENTIFICATION NUt!BER _lO.._I_l. <br /> lei <br /> Svf`G�e` �,. _ _ _ .-_.�.-__...-.-�--- PATE OF FUNCTION - <br /> ,_�_-_.- _ TELEPHONE NJ* _- DAY_OF FUNCTION _ " /! F � <br /> STREET ADDRESS `' <br /> 1 ....-.� 1__:_•�—•- DA3clY <br /> -- - � '-�� NUMBER OF PLAYERS <br /> -_-..__---- ZIP CODE TIME OF FUNCTION _-_ .-- --"-�- <br /> CITY DF, <br /> TOWN -- _--- 0e <br /> s <br /> C <br /> N SCI4EDULE.1 CASINO FUNCTION INCOME STATEMENT <br /> H A. RECEIPTS <br /> G : <br /> 1. ADMISSION TICKETS (FROM CONTROL SHEET EO LINE 6) .... ... ... . ........ .. $ <br /> F d — <br /> W 2. RAFFLE TICKETS (FROM CONTROL SHEET OE TOTAL COL.8) ..... $ <br /> ..........,. <br /> $ <br /> p 3. GAMING TABLES (FROM CONTROL SHEET FO TOTAL COL. 1) <br /> F4. OVER/SHORT (FROM CONTROL SHEET OH LINE 13) . ... •••••••••• ' "" $ rO / c <br /> 5. OTHER RECEIPTS <br /> . ... ... . . .. ........ ... .. <br /> k . <br /> 6. GROSS RECEIPTS (ADD LINES 1 THRU 5) ... .. ... .......................... .. <br /> Q . <br /> m B. EXPENDITURES <br /> N <br /> a1. CASH PRIZES (COMPLETE SCHEDULE 2 AND ENTER TOTAL) ..... .. . ...... ... .. $ <br /> F - <br /> 2. CHIP REDEMPTIONS (FROM CONTROL SHEET O LINE 17) .. ...... . .. .. . ... ... $ <br /> F 3. TAX DUE (LINE 6, PART A x .05) .. . ... .. . ... ... .. . ... $ 7 / <br /> 4 4. PENALTY & INTEREST (SEE PAR. C PAGE 2) ......... $ +� <br /> $ CHECK# ( $ <br /> 1 • ✓ <br /> 5. TOTAL TAX DUE (ADD LINES 3 AND 4) Q: <br /> 6. EQUIPMENT SUPPLIER FEE. . ... ... ... . .. ...... .. <br /> CHECK # ( —) $ <br /> 1 NAME OF FIRM — <br /> Y <br /> 0 C CHECK NO. PAYEE <br /> DESCRIPTION <br /> TT 7. f $jr _ <br /> > $ <br /> s. <br /> J <br /> 11. j <br /> �m 12. $ <br /> "k <br /> U 13. $ <br /> OU 14. $ <br /> A = ..................... <br /> 15. TOTAL EXPENDITURES(ADD ITEMS 1 THRU 14) ........ ... .......... ........•• <br /> I ' <br /> C. NET PROFIT OR (LOSS) 3 <br /> 1. FROM LINE 6,PART A DEDUCT LINE 15 PART B ... ... .. . ... <br /> NET PROFIT OR (LOSS) $ <br /> (OVER) <br /> FORM CFT-1 (Revised 1981) ---- <br />