HUEY & ASSOCIATES, P.C. NON-PROFIT TAX ORGANIZER - 990

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1 HUEY & ASSOCIATES, P.C. NON-PROFIT TAX ORGANIZER ORG1 Please fill out the information below unless it is not applicable to your organization. Organization Information: Organization Name: Address: (if changed) TIN #: Date of Move (if applicable): State ID(s): State: ID: State: ID: State: ID: State: ID: Accounting Method for Taxes: (Circle one) Cash Accrual Other: Contact Information: Name: Phone: (Office) (Cell) Web Address: Address to Mail Completed Tax Returns: Please provide the following information for your Non-Profit (if applicable): New Clients (If you have not used Huey & Associates tax services before, please check all provided items): Audit Reports General Ledger\Trial Balance Depreciation Schedules Settlement Statement for properties IRS Determination letter for qualified plans Schedule A for prior 5 years Application for Exemption Form 1023\1024 Any IRS & State Tax Notices Prior Year Tax Returns for 3 years Balance Sheet & Statement of Activities\Financials Statement of Functional Expenses Application for exemption Articles of Incorporation\Bylaws IRS notification of exempt status Year of Formation Copies of all K-1 s received Revised 1/31/2013 1

2 ORG2 Balance Sheet/Income Statement Check yes/no for all appropriate questions or to indicate that you will provide the requested documents. Yes No 1 Please provide a copy of your Accounting/QuickBooks Accountants Copy File (.QBA) or your QuickBooks File (.QBW) If you use QuickBooks, please provide us with a QuickBooks username and password: QB Username 1: Password 1: QB Username 2: Password 2: 3 If you do not use QuickBooks, please provide the following in an electronic format: Copy of balance sheet for current tax year Copy of balance sheet for previous tax year Copy of income statement for current tax year Copy of general ledger for current tax year 4 If you do not use QuickBooks, please indicate which accounting software package you use and call us for instructions on how to deliver the above requested documents... Peachtree Quicken QuickBooks Macintosh Adjusting Journal Entries 5 If any adjusting entries are needed to keep your accounting books balanced, how would you like to receive the adjusting entries? (Please check one option only.) QuickBooks Accountants Copy Mail Want us to enter adjustments Advisor Information 6 Please provide contact details for any advisors that work with you on financial items. Title: Name & Address: Telephone #: Fax #: Address: Attorney Banker Insurance Broker Other: Other: Revised 1/31/2013 2

3 All clients please fill out or provide the information requested in the following sections: ORG3 Organization Information Statement of Program Accomplishments Check yes/no for all appropriate questions or to indicate that you will provide the requested documents. Yes No 7 Engagement letter signed, dated, and provided to Huey & Associates?. 8 If you have received any IRS or state notices, check yes and provide copies for us... May the IRS discuss questions about this return with the preparer? If yes, please initial: Briefly describe the organization s mission and its most significant activities: Indicate the number of voting members: In the governing body That are independent Indicate the number of volunteers who worked with the organization during the year (estimate if exact number unknown) Organization Questions Regarding Other IRS Filings and Tax Compliance 9 At any time during the calendar year, did the organization have an interest in, or signature authority over, a financial account in a foreign country? If yes, the Form TD F must be filed by June 30 of each year. (NOTE: Significant penalties for failure to file) 10 Was the organization a party (or was it notified that it was a party) to a prohibited tax shelter transaction at any time during the year? 11 Did the organization solicit any contributions that were not tax deductible? If yes, did the organization include with every solicitation an express statement that such contribution or gift was not tax deductible? For organizations that receive contributions under IRC Section 170(c): For quid pro quo contributions in excess of $75 received by the organization was a written statement provided to donor (includes deductible limit, estimate of value) Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? If yes how many forms filed Did the organization during the year receive any funds directly or indirectly to pay premiums on a personal benefit contract? Did the organization during the year pay any funds directly or indirectly for premiums on a personal benefit contract? For all contributions of qualified intellectual property did the organization file form 8899 as required? For contributions of cars, boats, airplanes and other vehicles did the organization files a 1098C as required? 12 For 501(c)(3) and other sponsoring organizations maintaining donor advised funds and 509(a) supporting organizations did the supporting organization, or a fund maintained by a supporting organization, have excess business holdings at any time during the year? 13 For 501(c)(3) and other sponsoring organizations maintaining donor advised funds did the organization make any taxable distributions under 4966 or make a distribution to a donor, donor advisor or related person? Revised 1/31/2013 3

4 ORG4 Organization Information Checklist of Required Schedules 14 Did the organization receive over $5,000 from any individual donor? Provide a list of names, addresses and the amount of contribution. 15 Does the organization website list any Political\Legislative activities? If yes Schedule C Parts I and II are required. 16 For 501(c)(3) organizations did the organization engage in any lobbying activities during the year? If yes Schedule C Part III is required. 17 For 501(c)(4), (5), and (6) organizations is the organization subject to lobbying notice, reporting requirements and proxy tax? If yes please provide a schedule of nondeductible dues notices and actual lobbying expenditures incurred. 18 Did the organization maintain donor advised funds? If yes Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization property, subject to the organization exclusive control? Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be used only for charitable purposes and not for the benefit of the donor or donor advisor or other impermissible private benefit? 19 Did the organization receive or hold conservation easements? 20 Did the organization hold collections, works of art, historical treasures or similar assets? (See Schedule D Part III) 21 Did the organization own any non publically traded investments? (See Schedule D Parts VI, VII and\or VIII) 22 Did the organization receive an audited financial statement prepared in accordance with GAAP? (See Schedule D Parts X, XI, XII, and XIII) 23 Is the organization a private school? If yes complete Part XII 24 Did the organization maintain an office, employees or agents, or conduct activities amounting to more than $10,000 outside the US? 25 Did the organization make more than $5,000 of grants or assistance to any organization or entity outside the US? If yes see Schedule F Instructions for reporting Requirements 26 Did the organization make more than $5,000 of aggregate grants or assistance to any organization or entity outside the US? If yes see Schedule F Instructions for reporting Requirements 27 Did the organization incur more than $15,000 for professional fundraising services? If yes see Schedule G Part 1 28 Did the organization raise more than $15,000 from fundraising events? If yes see Schedule G Part II 29 Did the organization raise more than $15,000 from gaming activities including raffles If yes see Schedule G Part III 30 Did the organization operate one or more hospitals? If yes see Schedule H for Reporting Requirements 31 Did the organization make grants of more than $5,000 to governments or organization in the US? If yes see Schedule Part I, II and Question Did the organization make grants of more than $5,000 to individuals in the US? If yes explain how the organization determines that those receiving disbursements from the organization in furtherance of it charitable programs qualify to receive payments and See Schedule I, Part III and Question 902. _ 33 Did the organization have a tax-exempt bond issue with a principal balance of more than $100,000 outstanding as of the end of the year? If yes, see Schedule K and complete Part XIII. Revised 1/31/2013 4

5 34 For 501(c)(3) and (4) organizations, did the organization engage in or become aware of any previous excess benefit transaction with a disqualified person during the year? If yes, see Schedule L, Part I. ORG5 35 Was a loan to or from a current or former officer, director, trustee, key employee, highly compensated employee or disqualified person outstanding as of the end of the tax year? If yes, see Schedule L, Part II 36 During the tax year, did any person who is a current or former officer, director, trustee or key employee: Continue to receive compensation after serving as an officer, director, trustee key employee or highly compensated employee? Receive compensation from the organization and any related organization in excess of $150,000? Receive or accrue compensation from any unrelated organization for services rendered to the organization? 37 Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, or substantial contributor, or to a person related to such an individual? If yes, see Schedule L, Part III. 38 During the tax year, did any person who is a current or former officer, director, trustee or key employee: Have a direct business relationship with the organization (other than as an officer, director, trustee or employee) or an indirect business relationship through ownership of more than 35% in another entity (individually or collectively with other person(s)) listed in Part VII, Section A? Have a family member who had a direct business relationship with the organization? Serve as an officer, director, trustee, key employee, partner, or member of an entity (or a shareholder of a professional organization) doing business with the organization? 39 Did the organization: receive more than $25,000 in noncash contributions or the use of materials, equipment, or facilities at no charge or at substantially less than fair rental value? If yes, provide a list indicating the value of each item, the amount of reported revenue and method used to determine value. (See Schedule M). have a gift acceptance policy that requires the review of any noncash gift that is not reasonably expected to be used to satisfy or further the tax exempt purpose of the organization and for which there is no readily available market to sell the item or determine its value? hire or use third parties or related organizations to solicit, process or sell noncash contributions? receive contributions of art, historical treasures, or other similar assets or qualified conservation contributions? (See Schedule M) 40 Did the organization: liquidate or dissolve and cease operations? If yes, provide details. (See Schedule N, Part I). sell, exchange or dispose of, or transfer more than 25% of its net assets? (See Schedule N, Part II). own 100% of an entity disregarded as separate from the organization (e.g. a wholly owned LLC)? (See Schedule R, Part I). If yes describe the organization (s): 41 Is the organization related to any tax-exempt or taxable entity (other than by association with a statewide or nationwide organization) through common membership, governing bodies, officers, etc.? If yes, refer to the instructions for Schedule R of the 2009 Form 990. The information required will depend upon the type of entity organization. 42 Is any related organization a controlled entity (i.e. where the organization owns at least 80% of the total combined voting power of all classes of stock)? Revised 1/31/2013 5

6 43 Determine if the organization owned a 50% or greater interest in any taxable corporation, organization or LLC during the year if so report name address, TIN, % ownership, nature of business, total income and year end assets. 44 Did the organization receive any membership dues or assessments? Were those for payment of benefits received? ORG6 45 Did the organization have any fundraising activities this year? Did the organization receive any contributions from other closely associated organization? Did the organization receive any contributions from federated fundraising agencies (such as United Way)? 48 Can you file for a group return under a separate TIN (will any member elect out of group return)? 49 List the states in which the organization solicits contributions: 50 Are you aware of any changes to income, deductions and/or credits reported on a prior year s tax returns? Has the organization made or received any below-market rate loans to determine imputed interest consequences? Have state returns and registration statements been prepared for all states in which the organization has a nexus or solicits contributions (review pass-through exposure) 53 For contribution of $250 or more received by a charitable organization was contemporaneous substation provided to donor? 54 Does the organization have unrelated business income in excess of $1,000: 55 Did the organization receive any grants that were for payment for services: Revised 1/31/2013 6

7 ORG7 Cash Information Check yes/no for all appropriate questions or to indicate that you will provide the requested documents. Yes No 56 Please provide copies of any year-end bank statements for all organization accounts Have you reconciled all organization bank accounts? If yes, please provide copies of bank reconciliations 58 Do any organization bank accounts have outstanding checks? If yes, please provide documentation of checks and indicate if any checks should be voided or marked as escheatable funds 59 Please provide copies of any year-end investment fund statements for all organization income Identify interest bearing versus non-interest bearing bank accounts. Notes Receivable 61 Did the organization give any loans to shareholders during the tax year? If new loans, please provide a copy of the promissory note and an amortization schedule Shareholder Borrower Purpose of Loan Year End Balance of Loan Payments Received this Tax Year Interest Expense 62 Did the organization give any other business loans during the tax year? If new loans, please provide a copy of the promissory note and an amortization schedule Borrower Purpose of Loan Year End Balance of Loan Payments Received this Tax Year Interest Expense Revised 1/31/2013 7

8 ORG8 Inventory Check yes/no for all appropriate questions or to indicate that you will provide the requested documents. Yes No 63 If applicable, please provide the fair market value of inventory at the end of the tax year: Fixed Assets 64 Was there any change in determining quantities, costs, or valuations between the opening and closing inventory? If yes, attach explanation. 65 During the tax year, did the organization sell or dispose of any assets used in the business? If yes, please provide the following Description of Asset Sold Sales Price Date Sold Date Acquired Original Cost or Basis Depreciation Claimed in Previous Years 66 Were any assets purchased during the year? If yes, list assets purchased below and include copies of purchase invoices: Asset Description Date Placed in Service Purchase Price (including Trade In) List states in which tax returns should be filed: 67 Did any shareholders contribute any assets to the organization during the year? If yes, provide a schedule of such assets received including date placed in service and shareholder s basis in such assets and fair market value of such asset. 68 Did the organization make any significant improvements or repairs? If yes, please provide the following: Description Expense Account Used 69 Did the organization buy/sell any real estate? If yes, please provide closing documents (settlement sheets, etc.) 70 Does the corporation own or lease any vehicles? If yes, provide the following information for each vehicle (NOTE: certain exceptions may apply for taxpayers with more than five vehicles): Vehicle Description Date Placed in Service Business Miles Commuting Miles Other Personal Miles Total Miles Average Daily Round Trip Commuting Distance 71 Does the organization own any other assets? If yes, complete the following.. Description Dollar Value at Year End Revised 1/31/2013 8

9 ORG9 Accounts Payable/Credit Cards Check yes/no for all appropriate questions or to indicate that you will provide the requested documents. Yes No 72 If applicable, please provide copies of any year-end credit card statements for all organization accounts. 73 Have you reconciled all organization credit card accounts? If yes, please provide a copy of the credit card reconciliation... Sales Tax Liability 74 If applicable, please provide a copy of the Year End Sales & Use Tax forms..... Notes Payable 75 Did the organization receive contributions or grants that contributors or grantors have designated as payable for one or more future years? If yes, provide a schedule describing each contribution or grant and indicate the total amount of each item and the amount applicable to each future period. 76 Did the organization enter into any loans agreements with shareholders during the tax year? If new loans, please provide a copy of the promissory note and an amortization schedule... Shareholder Lender Purpose of Loan Year End Balance of Loan Payments Received This Tax Year Interest Expense 77 Did the organization enter into any other business loan agreements during the tax year? If new loans, please provide a copy of the promissory note and an amortization schedule Lender Purpose of Loan Year End Balance of Loan Payments Received This Tax Year Interest Expense 78 Did you receive any restricted contributions? Net Assets 79 Did you release any previously restricted funds? If yes provide a schedule of restricted funds Revised 1/31/2013 9

10 ORG10 Program Services 80 Is the organization a 501C(3), 501C(4) and 4947(a)(1) Trust if so provide: Report of total expenses, total grants\allocations to others and total expenses and revenue for each program service Describe the organization s other program services. Report the revenue expenses and grants from all other programs in total: 81 For each of the organization s three largest program services offered based on expenses incurred prepare a statement that fully describes the services provided with specific measurements (number of persons served, session held, and research performed, etc.): 82 Is the organization a 501C(3), 501C(4) and 4947(a)(1) Trust if so provide: Report of total expenses, total grants\allocations to others and total expenses and revenue for each program service Describe the organization s other program services. Report the revenue expenses and grants from all other programs in total: Program 1: Description Total Expenses Total Grants\Income Program 2: Description Total Expenses Total Grants\Income Program 3: Description Total Expenses Total Grants\Income 83 Did the organization cease conducting or make significant changes in how it conducts any program services? If yes describe: 84 Did the organization conduct more than 5% of its exempt or unrelated activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? Revised 1/31/

11 ORG11 Organization Information Contributions and other Revenues 85 See the instruction for Schedule B for the definition of a contribution. For 509(a)(2) organizations, governmental contributions are included. Use the accounting method that is being used for the rest of the return to prepare Schedule B. 86 Prepare a schedule showing the following: Each contributor whose aggregate contributions were $5,000 or more ( 507(c)(7), (8) & (9) use $1,000 as the threshold); ( 509(a)(1) organizations use the greater of $5,000 or 2% of PART VIII 1h, Form 990, as the threshold). Each listed contributor's address Aggregate amount contributed Cash, non-cash or payroll deduction FMV of non-cash property contributed Date of contribution Description of property, if applicable 87 Did the organization provide written acknowledgement to donors of individual contributions of $250 or more 88 If membership dues and contributions have been reported in one income category, provide a breakout (what portion of dues represent contributions). 89 Did the organization sell, exchange or otherwise dispose of tangible personal property for which it filed Form 8282? If yes, indicate the number of Forms 8282 filed. 90 Does the organization raise funds through any of the following activities (Schedule G): Mail solicitations solicitations Phone solicitations In-person solicitations Solicitation of non-governmental grants Solicitation of governmental grants Special fundraising events 91 List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registering or licensing. Revised 1/31/

12 92 Did the organization have a written or oral agreement with any individual (including officers, directors, trustees or key employees listed in Part VII) or entity in connection with professional fundraising services? If yes, provide a list of the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is to be compensated at least $5,000 by the organization indicating the following: Name of individual or entity (fundraiser) Nature of activity Did fundraiser have custody of funds Y/N Gross Receipts Amount paid to fundraiser ORG12 Amount retained by organization 93 For your two largest fundraising events, all other fundraising events and any raffle or other gaming events that were held during the year, please complete the following Gross Receipts Less charitable contributions Gross event revenue Cash prizes Non-cash prizes Rent/facility cost Other direct expenses Total expenses Net event/gaming income Fundraising Event #1 Fundraising Event #2 Total of All other Events (# ) Raffle or Gaming 94 Did the organization conduct any gaming activities, including raffles, during the year? If yes: 95 Indicate the state(s) in which the organization operates gaming activities Is the organization licensed to operate gaming activities in each of these states? Were any of the organization's gaming licenses revokes during the year? Does the organization operate gaming activities with nonmembers? Is the organization a grantor, beneficiary or trustee or a member of a partnership or other entity formed to administer charitable gaming? Revised 1/31/

13 ORG13 Investment Income Check yes/no for all appropriate questions or to indicate that you will provide the requested documents. Yes No 96 Please provide a copy of all Form 1099-INT and/or statements for all interest income, including tax-exempt interest. Please indicate the amount of 1099 s and/or statements attached:. 97 Please provide a copy of all Form 1099-DIV and/or statements for all dividend income, including tax-exempt interest. Please indicate the amount of 1099 s and/ or statements attached:. 98 Please enclose all Forms 1099-B and 1099-S. Also include a copy of Realized Gains & Loss Schedule. Indicate how many statements provided: Income From Unrelated Business Activities (UBIT) Complete if Gross Income from Unrelated Business is $1,000 or more 99 Does the organization need to file 990T: There is an unrelated trade or business There is debt financed property A organization, LLC, S corporation or any other entity interest is owned Income is received from royalty agreement Consider filing a zero 990T to start the running of the statue of limitations 100 Is it a Trade or Business? Is it carried on for production of income from selling goods or services? Regularly carried on? Not substantially related to an organizations exempt purpose? 101 Did the organization have any gross receipts of $1,000 or more from a trade or business not related to the organization s exempt purpose? If so provide the income and expense detail related to the activity: 102 Please provide a year-end financial statement of the business 103 Provide income and direct expenses related to activity: Income: Expense: Net Income: 104 Advertising Sales: Gross Advertising Income: Direct Advertising Costs: If Net Income then: Add Circulation Income: (Include allocation of membership receipts) Less Readership Costs: 105 Select yes and provide any K-1 s from Organization Investments 106 Does the organization website list any UBTI activities? 107 Does the organization website list any activities that may affect tax-exempt status? Revised 1/31/

14 Income From Organizations, Estates, Trusts, LLC s or S Corporations 108 Enclose all schedule K-1 s, both federal and state, that you have received. Indicate the number of K-1 s: 109 Identify any K-1 Forms that you have not received below: Name: Source Code: Federal ID#: ORG14 Other Income 110 Enclose related Forms 1099 or other forms of correspondence (e.g., state, local income tax refund, etc.)... Functional Expenses 111 For all organizations other than 501(c)(3) and (c)(4) organizations and 4947(a)(1) charitable trusts, does the organization desire to allocate expenses under the classifications of expenses related to management/general, program services, and fundraising? If yes, categorize expenses on the organization's trial balance. 112 Did the organization provide assistance to any Individuals? 113 Did the organization make foreign grants? (Procedures and disclosures for foreign grants differ from the information required for domestic grants. See the instructions for Schedule F Form 990.) 114 Does the organization provide any of the following benefits to members or dependents (do not include employment-related benefits provided to officers and employees)? If yes, provide a schedule showing amounts of: Death, sickness, hospitalization, or disability benefits Unemployment compensation benefits Other benefits (describe) 115 Did the organization make payments to affiliates? If yes, provide a schedule listing the following: Name and address of each affiliate receiving payments Amount and purpose of the payments 116 If the organization incurred joint costs for a combined educational campaign and fundraising solicitation, provide a schedule that allocates the amount incurred among programs services, management and fundraising. 117 Please provide the schedule allocating expenses by the Functional Expense: Program Add definition Administrative Fundraising Revised 1/31/

15 Tax Payments Please provide details about your tax payments for the tax year: 118 Description Federal Date Paid Federal Amount Paid State Date Paid State Amount Paid Prior Year Overpayment Applied 1 st Quarter 2 nd Quarter 3 rd Quarter 4 th Quarter Payroll Information ORG15 Check yes/no for all appropriate questions or to indicate that you will provide the requested documents. Yes No 119 Does the organization have qualified retirement plan(s)?..... If yes, do we need to prepare the 5500 series form(s)? Does the organization have a cafeteria plan(s)?... If yes, do we need to prepare the 5500 series form(s)? Does the organization have a non-qualified retirement plan(s) or other benefit plan(s)? If yes, please describe the plan(s): 122 Did the organization include taxable fringe/welfare benefits such as health insurance, group life insurance, educational assistance, expense allowances, and personal use of organization vehicles as compensation on employees Forms W-2 and, if applicable, subject such amounts to payroll taxes? Please provide copies of the following forms that were filed. (Please check the forms provided) W-2/W / All Year End State Withholding & Unemployment Filings 124 Does the organization maintain a written policy statement that prohibits all personal use of vehicles, including commuting, by employees? Does the organization maintain a written policy statement that prohibits personal use of vehicles, excluding commuting, by employees? Does the organization treat all use of vehicles by employees as personal use? Does the organization provide more than five vehicles to employees and retain the information received from employees concerning the use of vehicles? Indicate the number reported in Box 3 of Form Indicate the number of Forms W-2G included 130 Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (raffle) winnings to winners? 131 Indicate the number of employees reported on Form W Did the organization file all required federal employment tax returns? 133 Does the organization require or maintain copies of vehicle logs?... Revised 1/31/

16 ORG16 Organization Information - Governance 134 Did any officer, director, trustee or key employee have a family relationship or a business relationship with any other officer, director, trustee or key employee? If yes describe. 135 Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? If yes describe. 136 Has the organization revised its governing documents and provided changes to the IRS. If yes, provide a complete copy of the revised documents and indicate the change(s). Did the organization become aware of a material diversion of the organization's assets? If yes, describe. 137 Does the organization have members or stockholders? 138 Does the organization have members, stockholders or other persons who may elect one or more members of the governing body? If yes, describe. 139 Are any decisions of the governing body subject to approval by members, stockholders or other persons? If yes, describe. 140 Did the organization contemporaneously document all meetings held or written actions undertaken during the year by the following: The governing body? Each committee with authority to act on behalf of the governing body? If no describe how records are kept of governing body decisions. 141 Does the organization have local chapters, branches or affiliates? If yes, does the organization have written policies and procedures governing the activities of chapters, affiliates and branches to ensure their operations are consistent with those of the organization? If no, describe how control is exercised on their activities. 142 Was a copy of the Form 990 provided to the organization's governing body before it was filed? If yes, describe the process, if any, the organization uses to review the Form Is there any officer, director, trustee, or key employee listed in PART VII who cannot be reached at the organization's mailing address? If yes, provide the names and addresses Revised 1/31/

17 144 Does the organization have a conflict of interest policy? ORG17 Are officers/directors/trustees required to disclose potential conflicts? Does the organization regularly and consistently monitor and enforce compliance with the policy? If yes, describe how this is done. 145 Does the organization have a written whistleblower policy? 146 Does the organization have a written document retention and destruction policy? 147 Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? The organization's CEO, Executive Director, or top management official Other officers or key employees of the organization 148 Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? If yes, has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization's exempt status with respect to such arrangements? 149 Provide a list of the states in which a copy of the return should be filed. (You may be required to file a return in any state where the organization owns or leases property, has employees or sells goods or services.) 150 List the states in which the organization solicits contributions. (Also see question 809 regarding registration) 151 Describe how the organization makes its Form 1023, 1024, 990, and/or 990-T ( 501(c)(3)s only) available for public inspection. 152 Describe whether (and how) the organization makes its governing documents, conflict of interest policy and financial statements available to the public. 153 State the name, physical address and telephone number of the person who processes the books and records of the organization. Revised 1/31/

18 ORG18 Compensation Information Continued Former Officer/Directors/Trustees That Were Employed Compensation Information 154 Complete the following schedule for all current officers, directors and trustees regardless of compensations as well as for key employees and the five highest compensated employees (other than officers or key employees) who earned over $100,000 for the calendar year ending during the organization s fiscal year. Current officers\director\trustees are those who held their position at anytime during the year. Also list any former officer, key employee or highly compensated employee who received more than $100,000 from the organization and any related organizations, and any former director or trustee that received, in the capacity as a former director or trustee, more than $10,000 of reportable compensation from the organization or any related organizations. Key employee is an employee of that organization ( other than an officer director or trustee) who meets all 3 of the following tests: Receives reportable compensation from organization and all related organizations in excess of $150,000. Has responsibilities, power, or influence over the organization as a whole similar to those of officers, directors or trustees or manages a discrete segment or activity that represents 10% or more of activities, assets, income or expenses of the organization as compared to the organization as a whole or has or shares authority to control or determine 10% or more of the organizations capital expenditures, operating budget, or compensation for employees. Is one of the 20 employees (that satisfy the $150,000 Test and Responsibility Test) with the highest reportable compensation from the organization and related organization for the year (if more that 20 only list 20 highest) Name: Title: Position: Hours per week: Reportable Compensation from the organization per W-2\1099: Reportable Compensation from the related organizations per W-2\1099: Estimated amount of other compensation from the organization and related organizations: Attach additional pages to report the requested information for all officers/directors/trustees. Revised 1/31/

19 155 Complete the following schedule for all former officers, directors and trustees who received compensation from the organization. Payments or loans to disqualified persons, former, officers, trustees and key employees (these are persons who were not employees at any time during the year) Name: Address: Severance\Ot her Cash Payments Non-qualified Deferred Comp Allowances Non-accountable reimbursement Value of Housing (taxable/nontaxable) Loans/Advances to Former Employees ORG Did any of the former directors or trustees receive more than $10,000 in his/her capacity as a former director or trustee? Note: Failure to report all items of compensation could result in the imposition of penalties on the individuals and certain managers within the organization. 157 Please indicate the total number of Independent Contractors who received more than $100,000 of compensation from the organization. Revised 1/31/

20 158 Complete the following schedule for the five highest paid service providers who received more than $100,000 from the organization. ORG20 Name & Business Address Description of Services Compensation 159 Are any of the officers/directors/trustees/key employees/members of the 5 highest paid groups or any of the independent contractors related to one another through a business or family relationship? If yes, please elaborate with regard to the relationship. 160 Did the organization pay premiums or receive money to pay premiums on a "personal benefit contract" (e.g. use of insurance products)? 161 During the tax year, has the organization, either directly or indirectly, engaged in any of the following acts with a trustee, director, principal officer, substantial contributor or creator of the organization or any person, taxable organization or corporation with which such person is affiliated as a relative, officer, director, trustee, majority owner, or principal beneficiary? If yes, provide an explanation of the transaction. A) -Sale, exchange or lease of property B) -Lending of money or other extension of credit C) - Furnishing of goods, services, or facilities D) - Transfer any part of the organization's income or assets? If yes, describe. E) - Payment or reimbursement of expenses if more than $1,000 F) - First-class or charter travel G) - Travel for companions H) - Tax indemnification or gross-up payments I) - Discretionary spending accounts J) - Housing allowance or residence for personal use K) - Health or social club dues or initiation fees L) - Personal services (e.g. maid, chauffeur, chef, etc.) Revised 1/31/

21 162 If questions 709) e-l are yes, Did the organization follow a written policy regarding payment or reimbursement or provision of expenses? Did the organization require written substantiation prior to reimbursing or allowing expenses incurred by all officers, directors, trustees? 163 Indicate which, if any, of the following the organization uses to establish the compensation of the organization's CEO/Executive Director. Check all that apply. Compensation committee Independent compensation consultant Form 990 of other organizations Written employment contract Compensation survey or study Approval by the board or compensation committee Other describe 164 Describe the process for determining and approving compensation and benefit payments to officers, directors and employees under the excess benefit rules 165 Did any of the persons listed above receive compensation from a related organization? If yes, provide details of individuals, amounts and the related organization. ORG During the year, did any officer, director, trustee or key employee: Receive a severance payment or change of control payment? 167 Participate in or receive payment from a supplemental nonqualified retirement plan? 168 Participate in or receive payment from an equity-based compensation arrangement? 169 Participate in or receive payment from an equity-based compensation arrangement? Revised 1/31/

22 ORG22 Revised 1/31/

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