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MINNESOTA DEPARTMENT OF REVENUE <br />Sales and Use Tax <br />MN ID: 7756699 Period End <br />Date Filed: <br />COUNTRY LOUNGE INC Amend: L—_� <br />3590 HOFFMAN RD <br />SAINT PAUL MN 551105222 Amend Date: <br />Thank you for using e-Services Minnesota for electronic paying and filing. <br />Filing Summan! (all locations): <br />Gross Receipts: $10,610 <br />Tax Line # Tax Line Description <br />100 <br />General Rate Sales Tax <br />ill <br />Liquor Gross Receipts Sales <br />112 <br />Liquor Gross Receipts Use <br />200 <br />Use Tax Purchases <br />210 <br />Variable Rate Purchases <br />440 <br />Transit Improvement Sales <br />441 <br />Transit Improvement Use <br />Page 1 <br />Dec-31-2011 <br />Jan-19-2012 <br />Taxable Units Rate Tax Due <br />$9,111 <br />6.875% <br />$626 <br />$6,548 <br />2.5% <br />$164 <br />$646 <br />2.5% <br />$16 <br />$1,021 <br />6.875% <br />$70 <br />$0 <br />Varies <br />$0 <br />$9,111 <br />0.25% <br />$23 <br />$1,021 <br />0.25% <br />$3 <br />Total Tax <br />$902 <br />See the following page(s) for detail by location. <br />