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<br />MINNY-SOT A REVY-NUE <br />LA WFUL GAMBLING MONTHLY SUMMARY and TAX RETURN <br /> <br />Organization Name <br /> <br />arrJ<.A THERINE UK. ORTH. CHURCH <br />"ddress <br />]600 W Hwv 96 <br />City <br />Ardcn lIills <br />Number of games reported <br />on Schedule B2s: 169 <br />This return includes <br />[ ] Schedule A ( . pages) <br /> <br />State Zip Code <br />MN 55]12 <br />[ I Amended return <br />[ I No gambling activity this month <br /> <br />Check any <br />that apply <br /> <br />_ [x 1 Schedule B2 (12 pages) <br /> <br />[xl Schedule F <br /> <br />(A) Gross receipts <br />Bingo. 1357086.00 <br /> <br />2 Raffles [ ] check if tax exempt, attach Schedu]e-ER. 2 0.00 <br /> <br />3 Paddlctickets 3 0.00 <br />4 Sub-Total (add lines] Ihrough 3) 4 1357086.00 <br />5 Last month line 6C, if it was negative. 5 0.00 <br /> I ] check when ending loss reporting <br />6 ^djusled Sub- Tolal (line 4 minus line 5). 6 1357086.00 <br />7 Interest and other income. 7 0.00 <br />8 Tipboards . 8 0.00 <br />.9 Pull tabs . <br /> 9 389188.00 <br />]0 Totals (add lines 6. 7. 8, 9). .10 1746274.00 <br /> <br />]] a. Gamb]ing tax on Bingo, Rames and Paddletickets (8.5% of line 6C) . <br /> <br /> <br />b. Combined-receipts lax (Schedule E, line 9). <br /> <br />^dd ]ines]]a and lib. <br /> <br /> <br />12 Control Board fee (effective 07103) mu]tiply line ]O^ by 0.1% (.00]). <br /> <br /> <br />] 3 Pay This Amount (line]] plus line 12) Check payable to Minnesota Revenue. <br /> <br />14 Gambling tax paid through distributors for Pulltabs & Tipboards <br /> <br /> <br />] 5 Tota] gambling laxes and fees (add lines ]3 and 14). <br /> <br /> <br />16 Gross profit after taxes and fecs (tine 10C minus line 15) and to line 17 on page 2 . <br /> <br />GI <br /> <br />License Number <br />31686 <br />MonthlY ear reported <br />Januarv 2005 for 12 months <br />Number of Sites <br /> <br />1 <br />[ ] Filing extension request <br />[ ] Final return <br /> <br />[ ] Barcode sheels ( <br /> <br />page.'2 <br /> <br />(B) Prizes <br />]015132.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />1015132.00 <br /> <br />] 0 15132.00 <br /> <br />0.00 <br /> <br />28] 624.00 <br /> <br />1296756.00 <br /> <br />a. <br /> <br />29066.09 <br />0.00 <br />II <br />12 <br />13 <br />]4 <br />15 <br />]6 <br /> <br />b. <br /> <br />I declare fhat all information on this summary and tax rcturu is truc, correct and complete. <br />~--- <br />Signature Date <br /> <br />Date <br /> <br />Chief <br />Executive <br /> <br />Signature <br />Gambling <br />Manager <br />Firm Name <br /> <br />VICTOR HUSHCIIA <br /> <br />SVIATOSLAV MIRZA <br /> <br />Signature <br /> <br />of <br />Prepan:r FRANK BELGEA <br /> <br />.lail wi;ll attachments to: Minnesota Revcnue, Mail Station 3350, St.Paul, MN 55146 - 3350 <br /> <br />(C) Net <br />341954.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />341954.00 <br /> <br />0.00 <br /> <br />341954.00 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />107564.00 <br /> <br />449518.00 <br /> <br />29066.09 <br /> <br />] 746.27 <br /> <br />30812.36 <br />8903.24 <br /> <br />39715.60 <br /> <br />409802.40 <br /> <br />Phone: - <br />Date <br /> <br />Phone: 651/47()-7696 <br />