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///amachwdh Slat, oCo�Ee�y C,onainis�ion ?\ <br /> CHARITABLE GAMING DIVISION <br /> P.O. Box 800 <br /> Braintree,Massachusetts 02184 ' <br /> �/� � Tel.617-849-5555 <br /> ROBERT O.CRANE v 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(V) <br /> TYPE OF ACTIVITY: RAFFLE BAZAAR ❑ OTHER (SPECIFY) 7 <br /> PLEASE TYPE OR PRINT IN INK <br /> NAME OF ORGANIZATION <br /> STREET ADDRESS OF ORGANIZATION AREA TELEPHONE NO <br /> CODE OF ORGANIZATION <br /> CITY OR TOWN R ID.NO.OF ORGANIZATION <br /> ZIP CODE DATE OF OCCASION <br /> SCHEDULEI <br /> COMPUTATION OF TAX: O -;2- <br /> j <br /> 1. Receipts From Sales / /� <br /> -qll 92 <br /> X �/ .......... .. . . . . .S La <br /> No.of Tickets or Cost Per Ticket <br /> Chances Sold or Chance <br /> 2. Other Receipts. . . . . . . .. . . . . . .. . ........ ........ .... . . . . .S <br /> 451, <br /> 3. GROSS RECEIPTS (Add Lines 1 and 2) ...... ........ . .. . . . ... ... ... ... .. .. .... . . S <br /> 4. TAX $— ,JJ y 2 X .05 44 R5- <br /> Amount of Line 3 <br /> 5. Penalty and Interest(See Par. D-Page 2) ............. . . . . . . ... . .. ........ .. ... ... S <br /> 6. TOTAL TAX DUE (Add Lines 4 and 5) .............. .. . . . . . . . .. . . . . ... .. .. ........ S <br /> SCHEDULE 2 <br /> Z <br /> N COMPUTATION OF NET PROFIT OR (LOSS): <br /> 1. GROSS RECEIPTS (From Line 3—Schedule 1) . ...... . . . . . .. . . . . . ....... .. .. ..... S <br /> to <br /> W 2. LESS EXPENSES: <br /> ° A. Total Prizes Awarded (Cash or Value) ............ . . . . . <br /> a <br /> GW I <br /> <N B. Other Expenses <br /> N <br /> W C. Tax Paid (Line 6—Schedule 1) .. .... . ..... ... .. . . . . . .5_ ,__ <br /> W0 q <br /> D. TOTAL EXPENSES (Add Items 2A-B-C) ..... . ... . . . . . . . . .. . .. . ..... .. . . .. . . .. $ <br /> 3. NET PROFIT OR (LOSS) (Subtract Line 2D From Line 1) . . . .. . . . . . .. . ... .. . . .. . . .. . $ <br /> DATE CHECK RECEIVED FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br /> DATE CHECK DEPOSITED <br /> MO ❑� EE NCHECK NV, <br /> UM ER NUMBER m ❑� m <br /> DAY YR (OVER) MO DAY YR <br />