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MUNiNt %JLH ,veparanent or xevenue - G -1 <br /> • Monthly Lawful Gambling Activity <br /> Summary and Tax Return <br /> Organization license number Month and year reported Number of premises <br /> A -00562 MfSC - 1 1 95 I IFS <br /> Organization name Address (sneer) City State Zip code <br /> Nat'l MS Soe&ety - MN Chapter 200 So. 12th Avenue Mpls, MN 55415 -1255 <br /> I — <br /> a Number of repo punk& tipboard and poddleecket ones Check if. — dus a an amended return you have an extension to life <br /> .— reported o n Schedule & 1 2s for Le mon I //__ _ <br /> t C W _ you hod no gambling activity • this a your final return <br /> 6 This return includes (check) a Schedule A ® Schedule &2 10 Schedule F <br /> Fill in number 01 pages below each schedule: <br /> A 8 C <br /> • <br /> Gross receipts Prizes 41 Net receipts <br /> 1 Bingo 1 /oo, 0 0 t 7 1 31, 1 7 37 <br /> 2 Raffles • 2 / b41, q 0 /o 2302 <br /> 3 Paddletickets .3 5' 3 / at le ss 2 (055 <br /> 4 Income from interest and dividends (fill <br /> in same amount in columns A and C) 4 P. <br /> 42 5 Add lines 1 through 4 5 /isa238' 75, a/4 5f (pa <br /> E 6 0 line 7c of last month's Form G -1 is negative, list <br /> 2 it (without parentheses) in columns A and C 6 i. <br /> 0 7 Subtract line 6 from line 5 7 ��sr238 7S a +,�OOa'� <br /> 8 Tipboards 8 5 <br /> a p q 0 1, 3 / / e ' - ' / //, <br /> 9 Pulltabs 9 / q a � 209 z `�qT' t`o f S9 7e/ <br /> • <br /> .10 Add lines 7 through 9. line 10c is our <br /> gross profit for the month y 10 air /NC/ C/ 3 4 S7/,, 00 53s 3,sa�. <br /> 11 Multiply line 7c by .095(9.5%) �iyy.s <br /> Wine 7c is o negative number, fill in zero here) (Effective 7-1-98) 11 3, frOa <br /> i s 12 Combined receipts tax, 0 any (from line 9 of Schedule E) 12 //3 �9 <br /> 13 Add lines 11 and 12 and PAY THIS AMOUNT. Make check payable to MN Dept. or Revenue 13 "70296, 7 <br /> 14 Total 1.9 percent tax paid during the month, 0 any (fisted on distributors' invoices <br /> 1 o _ _ for pulltabs and tipbaards) 14 5a, Ls/ <br /> � <br /> IL P • 15 Add lines 1 3 and 14 15 / �D81 / 0�7 <br /> a 1 6 Gross pro a state taxes (subtract line 15 from line 10c) 16 �4 S t �� <br /> Fill in the result here and on line 17 on the back of this form. <br /> 1 declare that all information on this summary and fax return is true, correct and complete. i <br /> o Stg a of ief exec officer pate SSignature of g manager � 9 <br /> gi (ee/T7— y 1 3- 9 y �. $ ate 's <br /> Prepare? tgnon:ye r. Daytime p e Prepare?' ID number <br /> rit ti.1 Al - u y It- (. - •II <br /> Mali this summary on .! fax r rn and attachments •: <br /> Ile MN Dept. of Revenue, Mail Station 3350, St. Paul, MN 55146-3350 <br /> once. . <br />