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<br />MINNESOTA REVENUE <br />LAWFUL GAMBLING MONTHLY SUMMARY and TAX RETURN <br /> <br />Gl <br /> <br />Organization Name <br />.ST. MARY ROM. ORTH. CHURCH <br />Address <br />854 WOODBRIDGE ST <br />City <br />ST PAUL <br />Number of games reported <br />on Schedule B2s: I 71 <br />This return includes <br />[ ] Schedule A ( pages) <br /> <br />I Check any <br />that apply <br /> <br />State Zip Code <br />~ 55117 <br />[ ] Amended return <br />[ ] No gambling activity this month <br /> <br />[x] Schedule B2 (12 pages) <br /> <br />[x] Schedule F <br /> <br />pages) <br /> <br />(A) Gross receipts <br />I Bingo . . . . . , . . . . . . . . . . . . . . , , , . . I 1402691.00 <br /> <br />2 Raffles [ ] check if tax exempt, attach Schedule-ER, 2 0,00 <br /> <br />3 Paddletickets . . . . , . . . . . . <br /> <br />. , 3 <br /> <br />0.00 <br /> <br />4 Sub-Total (add lines I through 3) <br /> <br />. . 4 <br /> <br />1402691.00 <br /> <br />5 Last month line 6C, if it was negative . . . 5 <br />[ J check when ending 10s5 reporting <br />6 Adjusted Sub-Total (line 4 minus line 5). . . . 6 <br /> <br />0,00 <br /> <br />1402691.00 <br /> <br />7 Interest, dividends and other income. <br /> <br />. . 7 <br /> <br />0.00 <br /> <br />8 Tipboards. . , . . ; . , . . . <br /> <br />. <br />9 Pulltabs. , . . . . . . , . , . <br /> <br />8 <br /> <br />0.00 <br /> <br />9 <br /> <br />380008.00 <br /> <br />10 Totals (add lines 6, 7,8,9). <br /> <br />,10 <br /> <br />1782699.00 <br /> <br />II a. Gambling tax on Bingo, Raffles and Paddletickets (8.5% of line 6C) . . . a. <br /> <br /> <br />b. Combined-receipts tax (Schedule E, line 9), . b. <br /> <br />Add lines llaand lib. . . . . . , , . . <br /> <br /> <br />12 Control Board fee (effective 07/03) multiply line lOA by 0.1% (.001), <br /> <br /> <br />13 Pay This Amount (line II plus line 12) Check payable to Minnesota Revenue. . <br /> <br />14 Gambling tax paid through distributors for Pulltabs & Tipboards . <br /> <br /> <br />15 Total gambling taxes and fees (add lines 13 and 14). . , , . . . . <br /> <br /> <br />] 6 Gross profit after taxes and fees (line 1 DC minus line 15) and to line 17 on page 2 . <br /> <br />License Number <br />00489 <br />MonthN ear reported <br />Januarv 2005 for 12 months <br />Number of Sites <br />I <br />[ ] Filing extension request <br />[ ] Final return <br /> <br />[ ] Barcode sheets ( <br /> <br />(B) Prizes <br />1006503.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />1006503.00 <br /> <br />1006503.00 <br /> <br />0.00 <br /> <br />274553.00 <br /> <br />1281056.00 <br /> <br />33675.98 <br />0.00 <br />II <br />12 <br />13 <br />14 <br />15 <br />]6 <br /> <br />1 declare that all information on this summary and tax return is true, correct and complete. <br />Signature Date Signature <br />Chief Gambling <br />Executive PHILLIP TOCONIT A Manager KELLY ROBINSON <br />Signature Firm Name <br />or <br />Preparer fRANK BELGEA <br /> <br />.ail with attachments to: Minnesota Revenue, Mail Station 3350, St.Paul, ~ 55146 - 3350 <br /> <br />(e) Net <br />396188.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />396188.00 <br /> <br />0.00 <br /> <br />396188.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />105455.00 <br /> <br />501643.00 <br /> <br />33675.98 <br />1782.70 <br />35458.68 <br />8626,76 <br />44085.44 <br />457557.56 <br /> <br />Date <br /> <br />Phone: 651.778-9440 <br />Date <br /> <br />Phone: 651/470-7096 <br />