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<br />MINNESOTA REVENUE <br />LAWFUL GAMBLING MONTHLY SUMMARY and TAX RETURN <br /> <br />GI <br /> <br />Minnesota Tax ID <br />2011963 <br /> <br />License Number <br />00489 <br />MonthlY ear reported <br />ianuarv 2007 for 12 months <br />Number of Sites <br />1 <br />[ ] Filing extension request <br />[ ] Final return <br /> <br />Organization Name <br />ST. MARY ROM. ORTH. CHURCH <br />USmail Address <br />854 WOODBRIDGE STREET <br />City <br />ST. PAUL <br />Number of games reported <br />on Schedule B2s: 202 <br />This return includes <br />[ ] Schedule A ( pages) <br /> <br />I Check any <br />that apply <br /> <br />Email Address <br />PM 6:30 <br />State Zip Code <br />~ 55117 <br />[ ] Amended return <br />[ ] No gambling activity this month <br /> <br />[x] Schedule B2 (14 pages) [x] Schedule F <br />(A) Gross receipts <br /> <br />[ ]Barcode sheets ( <br /> <br />(B) Prizes <br />1105123.00 <br /> <br />I Bingo. . . . . . . . . . . . . . . . . . . . . . . . . I <br /> <br />1433712.50 <br /> <br />2 Raffles [ ] check if tax exempt, attach Schedule-ER. 2 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />3 Paddletickets . . . . . . . . . . . 3 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />4 Sub-Total (add lines I through 3) . 4 <br /> <br />1433712.50 <br /> <br />1105123.00 <br /> <br />5 Last month line 6C, if it was negative . 5 <br />[ ] check when ending loss reporting <br />6 Adjusted Sub-Total (line 4 minus line 5). . 6 <br /> <br />0.00 <br /> <br />1433712.50 <br /> <br />1105123.00 <br /> <br />7 Interest and other income. <br /> <br />7 <br /> <br />0.00 <br /> <br />8 Tipboards. <br /> <br />8 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />9 Pulltabs . <br /> <br />.9 <br /> <br />449958.00 <br /> <br />32927 1.00 <br /> <br />10 Totals (add lines 6,7,8,9). <br /> <br />.10 <br /> <br />1883670.50 <br /> <br />1434394.00 <br /> <br />II a. Gambling tax on Bingo, Raffles and Paddletickets (8.5% ofline 6C) . <br /> <br /> <br />b. Combined-receipts tax (Schedule E, line 9). <br /> <br />Add lines Ila and lib. . . . . . . . . . . . . . <br /> <br /> <br />12 Control Board fee, 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 /> <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 />16 Gross profit after taxes and fees (line 10C minus line 15) and to line 17 on page 2 . <br /> <br />27930.11 <br />0.00 <br />11 <br />12 <br /> <br />a. <br /> <br />b. <br /> <br />pages) <br /> <br />(C) Net <br />328589.50 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />328589.50 <br /> <br />0.00 <br /> <br />328589.50 <br /> <br />0.00 <br /> <br />0.00 <br /> <br />120687.00 <br /> <br />449276.50 <br /> <br />13 <br /> <br />27930.11 <br />1883.67 <br />29813.78 <br />9808.95 <br />39622.73 <br />409653.77 <br /> <br />14 <br /> <br />15 <br /> <br />16 <br /> <br />I declare that all information on this summary and tax return is true, correct and complete. <br />Signature Date Signature Date <br />Chief Gambling <br />Executive AUREL CERNEA Manager KELLY ROBINSON Phone: 651-778-9440 <br />Signature Finn Name Date <br />of <br /> <br />Preparer FRANK BELGEA <br /> <br />Phone: 651A70-7696 <br /> <br />Mail with attachments to: Minnesota Revenue, Mail Station 3350, StPaul, ~ 55146 - 3350 <br />