Pace & Hawley, LLC Certified Public Accountants Form 990 Return of Organization Exempt From Income Tax Robert Pace, CPA, - Nathan Hawley, CPA PO Box 603 - Montpelier, VT 05601 TEL (802) 461-2587 - FAX (802) 476-5791
Please complete the following information: 1. Basic information: Organization name Address EIN Website Contact name Contact phone number Contact email 2. Description of the organization s mission statement if different from prior year. 3. Description of the organization s programs if different from prior year -2-
4. Please provide the following data for each board member, director and/or key employee: Name Title Address Average # hours Worked per week Amount of Compensation for this tax year 5. If, during the year any depreciated assets were sold, traded in or discarded, please provide a description of the asset sold, the date of the sale and the amount of the proceeds from the sale. 6. If assets were purchased during the year please provide me a detail including description of asset, date purchased, and cost. -3-
7. Please provide the following data related to any contributor (individual or entity) who contributed over $5,000 or more during the tax year (Note: Contributor Type should be one of the following: individual, business, governmental organization, other 501(c)3, private foundation.) Amount Contributed in Contributor Name Contributor Address Contributor Type* this Tax Year 8. Estimated number of volunteers 9. If there were donated services not booked in the accounting system please provide a description of the service and estimated fair market value 10. For each fundraising event where gross receipts exceed $5,000, please provide the direct event expenses. -4-
Please provide us with the following information: 11. Signed Engagement Letter (See engagement letter at page 7) 12. Financial data for the year: QuickBooks Password (Note: please provide a regular QuickBooks backup NOT an accountant s copy. Also please do not change any data in QuickBooks for the year we are preparing the tax return for after you have provided us with the financial data. It is a good practice to close the period so that no accidental changes are made to the data) 13. A copy of the organization s W-3 for this tax year and W-2s for any board member, director or key employee for this tax year 14. A copy of the organization s form 1096 and the name, address and amount paid for each contractor whom the organization paid more than $100,000 in this tax year 15. If using the accrual method of accounting please provide an accounts payable and receivable listing. 16. Inventory value at cost. 17. Please provide a method of allocating expenses into functional classifications; program, admin and fundraising. Note: expenses can be allocated by a percentage, actual allocation or some other reasonable and consistent method. Please complete the following questionnaire: (For Questions #18 through #33 please provide detail information for any question which the Organization answered yes.) Did the organization 18....engage in any lobbying activities? Yes No 19. engage in any political campaign activities? Yes No 20. maintain any donor advised funds? Yes No 21. hold or receive any conservation easements? Yes No 22. have more than $10,000 in grants, fundraising or program services fees outside of the United States? Yes No 23. maintain an office or pay employees outside the United States? Yes No -5-
24. pay more than $5,000 in grants or assistance to organizations or individuals located outside the United States? Yes 25. have outstanding at the end of the year an loans to No or from an officer or key employee? Yes No 26. have a business relationship during the year with an officer, key employee or family member thereof? Yes No 27. receive more than $25,000 in non-cash contributions during the year? Yes No 28. make any transfers to an exempt non-charitable related organization? Yes No 29. fail to file required payroll forms? Yes No 30. earn more than $5,000 in income unrelated to its exempt purpose? Yes No 31. have any foreign bank accounts or investment accounts during the year? Yes No (Note: if yes the Organization is required to file U.S. Treasury Form TD F 90-22.1 which is NOT filed with the tax return and is due June 30 th every year for the preceding calendar year.) 32. make any substantial changes to its activities, mission or exempt purpose? Yes No 33. pay health care benefits to any of its employees? Yes No 34. have a written whistleblower policy? Yes No 35. Will the Board review the 990 prior to its filing? Yes No Completed By Signature Date Printed Name -6-
Pace & Hawley, LLC Certified Public Accountants Dear Client: Engagement Letter Thank you for selecting Pace & Hawley, LLC to assist you with your tax affairs. This letter confirms the terms of our engagement with you and the nature and extent of services we will provide. We will prepare your form 990 using information you provide to us. We may ask for clarification of some items, but we will not audit or otherwise verify the data you submit. This engagement is limited to the preparation of Form 990 Return of Organization Exempt Form Income Tax only and we will not prepare other tax filings that may be required, including, but not limited to sales or excise tax filings. If you identify any other required tax filings you may engage us for those items separately. It is your responsibility to provide information required for preparation of complete and accurate returns. Please use the 990 organizer posted on our website as it will help you avoid overlooking important information and contribute to efficient preparation of your returns. You should keep all documents, canceled checks and other data that support your reported income and deductions. They may be necessary to prove accuracy and completeness of the returns to a taxing authority. You are responsible for the returns, so you should review them carefully before you sign them. Our work will not include any procedures to discover defalcations or other irregularities. The only accounting or analysis work we will do is that which is necessary for preparation of your income tax returns. Your returns may be selected for audit by a taxing authority. In the event of a tax examination, we can arrange to be available to represent you. Such representation will be a separate engagement for which an engagement letter will be provided to you. Our fee for preparation of your tax returns will be based on the amount of time required at standard billing rates. All invoices are due and payable when return is provided to you. To affirm that this letter correctly summarizes your understanding of the arrangements for this work, please sign this letter in the space indicated and return it to us. We appreciate your confidence in us. Please call if you have questions. Sincerely, Pace & Hawley, CPAs Accepted By: (Name) Date (Title) -7-