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Massachusetts State Lottery Commission � <br />CHARITABLE GAM NG DIVISION <br />P.O. BOX 3723 <br />TIMOTHYP. CAHILL BOSTON, MA 02241-3723 JOSEPH C. SULLIYAN <br />%u44Wrar. 4ar(-ccickor ��,aor4l TEL- 781-849-5555:1p �. Z7�ucta <br />FAX 781-849-5554. <br />RAFFLE AND/OR BAZAAR TAX RETURN <br />FILE RETURN AND PAYMENT <br />WITHIN 10 DAYS AFTER OCCASION <br />TO ABOVE ADDRESS <br />(SEE PENALTIES PAGE 2 - PAR. A- THROUGH E.) <br />CHECK (4) <br />TYPE OF ACTIVITY: RAFFLE (YJ' BAZAAR ❑ <br />R FAST TYPF OR PRINT IN INK <br />SCHEDULEI <br />COMPUTATION OF TAX: <br />1. RECEIPTS FROM SALES <br />J�' <br />/d <br />©O XY'/=D0 <br />No. of Tickets aCoss per Ticket <br />Chances Sad of Chance <br />FON MASSAGp/SETTS STATE LOTTERY COMMISSION USE ONLY <br />IDENTIFICATION NUMBER Received . <br />OTHER (SPECIFY) ❑ <br />2- OTHER RECEIPTS <br />................................................ <br />S /0200 =00 <br />D :DO <br />3. GROSS RECEIPTS (ADD LINES LAND 2) .........- <br />S r-00 :O0 <br />ZF LODE <br />4 -TAX$ %COD .00 X.05 .... ---„--„ .....................S <br />iyD:DO <br />DATE OF OCCASpN <br />O <br />Amount of Line 3 . <br />� <br />w <br />/ <br />5. PENALTY AND INTEREST (SEE PAR. D- PAGE 2)-------------- _ <br />SE,aT d0 d00 <br />2- OTHER RECEIPTS <br />................................................ <br />S /0200 =00 <br />D :DO <br />r 2. LESS EXPENSES: <br />°w A. TOTAL PRIZES AWARDED (CASH ORVALUE) .................... $ <br />wg <br />B. OTHER EXPENSES <br />u 2y C. TAX PAID (LINE 6-SCHEDULEI) .-.,,,-„--------------------- $_ �D :OO �5 <br />Ix <br />D. TOTAL EXPENSES (ADD ITEMS 2A -8-C) $ 7 �. ;,�pd <br />............. ............................. <br />n m ... <br />.a- « 3- NET PROFIT OR (LOSS) (SUBTRACT LINE 2D FROM LINE 1)�ry�7 <br />FOR MASSACHUSETTS STATE LOTTERY COMMISMN USE ONLY DATE CHECK RECEIVEDII�j�' DATE CHECK DEPOSITED <br />No m mCHEC <br />NO K W. <br />NUMBER m m m W <br />MO DAY YR <br />MO DAY YR <br />RBT (OVER) <br />3. GROSS RECEIPTS (ADD LINES LAND 2) .........- <br />S r-00 :O0 <br />4 -TAX$ %COD .00 X.05 .... ---„--„ .....................S <br />iyD:DO <br />Amount of Line 3 . <br />w <br />5. PENALTY AND INTEREST (SEE PAR. D- PAGE 2)-------------- _ <br />S <br />j-6. <br />TOTAL TAX DUE (ADD LINES 4AND 5)------------------- <br />s 60 OD <br />....... <br />a <br />SCHEDULE 2 <br />s <br />COMPUTATION OF NEI PROFIT OR R nSS1' <br />0 <br />1- GROSS RECEIPTS (FROM LINE 3 -SCHEDULE I),,,--„-1---.--.. <br />S/0Za(j :QO <br />r 2. LESS EXPENSES: <br />°w A. TOTAL PRIZES AWARDED (CASH ORVALUE) .................... $ <br />wg <br />B. OTHER EXPENSES <br />u 2y C. TAX PAID (LINE 6-SCHEDULEI) .-.,,,-„--------------------- $_ �D :OO �5 <br />Ix <br />D. TOTAL EXPENSES (ADD ITEMS 2A -8-C) $ 7 �. ;,�pd <br />............. ............................. <br />n m ... <br />.a- « 3- NET PROFIT OR (LOSS) (SUBTRACT LINE 2D FROM LINE 1)�ry�7 <br />FOR MASSACHUSETTS STATE LOTTERY COMMISMN USE ONLY DATE CHECK RECEIVEDII�j�' DATE CHECK DEPOSITED <br />No m mCHEC <br />NO K W. <br />NUMBER m m m W <br />MO DAY YR <br />MO DAY YR <br />RBT (OVER) <br />