Form 199 - California Exempt Organization Annual Information Return - 2016
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1
2California Exempt Organization
TAXABLE YEAR
FORM
199
2016
Annual Information Return
Calendar Year 2016 or fiscal year beginning (mm/dd/yyyy)
, and ending (mm/dd/yyyy)
.
Corporation/Organization name
California corporation number
Additional information. See instructions.
FEIN
Street address (suite or room)
PMB no.
City
State
Zip code
Foreign country name
Foreign province/state/county
Foreign postal code
J If exempt under R&TC Section 23701d, has the organization
A First Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
engaged in political activities? See instructions. . . . . . . . . .
Yes
No
B Amended Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
K Is the organization exempt under R&TC Section 23701g? . .
Yes
No
C IRC Section 4947(a)(1) trust . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If “Yes,” enter the gross receipts from nonmember sources . . $
D Final Information Return?
L If organization is exempt under R&TC Section 23701d and
Dissolved
Surrendered (Withdrawn)
Merged/Reorganized
meets the filing fee exception, check box.
Enter date: (mm/dd/yyyy)
____ / _____ / _______
No filing fee is required. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E Check accounting method: (1)
Cash (2)
Accrual (3)
Other
M Is the organization a Limited Liability Company? . . . . . . . . .
Yes
No
F Federal return filed? (1)
990T (2)
990PF (3)
Sch H (990)
N Did the organization file Form 100 or Form 109 to report
taxable income? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
(4)
Other 990 series
O Is the organization under audit by the IRS or has the IRS
G Is this a group filing? See instructions . . . . . . . . . . . . . . . . .
Yes
No
audited in a prior year?. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
H Is this organization in a goup exemption . . . . . . . . . . . . . . . . .
Yes
No
P Is federal Form 1023/1024 pending?. . . . . . . . . . . . . . . . . . . .
Yes
No
If “Yes,” what is the parent’s name?
Date filed with IRS
I Did the organization have any changes to its guidelines
not reported to the FTB? See instructions. . . . . . . . . . . . . . .
Yes
No
Part I Complete Part I unless not required to file this form. See General Instructions B and C.
1
00
1 Gross sales or receipts from other sources. From Side 2, Part II, line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
00
2 Gross dues and assessments from members and affiliates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
00
3 Gross contributions, gifts, grants, and similar amounts received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Total gross receipts for filing requirement test. Add line 1 through line 3.
Receipts
00
and
This line must be completed. If the result is less than $50,000, see General Instruction B. . . . . . . . . . . . . . . . .
4
Revenues
5
00
5 Cost of goods sold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
00
6 Cost or other basis, and sales expenses of assets sold . . . . . . . . . . . . . . . . . . .
7
00
7 Total costs. Add line 5 and line 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 Total gross income. Subtract line 7 from line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
00
9
00
9 Total expenses and disbursements. From Side 2, Part II, line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Expenses
10 Excess of receipts over expenses and disbursements. Subtract line 9 from line 8 . . . . . . . . . . . . . . . . . . . . . . . .
10
00
11
00
11 Total payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
00
12 Use tax. See General Instruction K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
00
13 Payments balance. If line 11 is more than line 12, subtract line 12 from line 11 . . . . . . . . . . . . . . . . . . . . . . . . .
Filing Fee
14
00
14 Use tax balance. If line 12 is more than line 11, subtract line 11 from line 12 . . . . . . . . . . . . . . . . . . . . . . . . . . .
15 Filing fee $10 or $25. See General Instruction F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
00
16 Penalties and Interest. See General Instruction J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
00
17 Balance due. Add line 12, line 15, and line 16. Then subtract line 11 from the result . . . . . . . . . . . . . . . . . . . .
17
00
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Title
Date
Telephone
Here
Signature
(
)
of officer
Date
PTIN
Check if self-
Preparer’s
signature
employed
Paid
FEIN
-
Firm’s name (or yours,
Preparer’s
if self-employed)
Use Only
Telephone
and address
(
)
May the FTB discuss this return with the preparer shown above? See instructions . . . . . . . . . . . . . . . . . . .
Yes
No
3651163
Form 199
2016 Side 1
C1
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