Form 199 - California Exempt Organization Annual Information Return

California Exempt Organization

YEAR

FORM

2001

Annual Information Return

199

For calendar or fiscal year beginning month ________ day ________ year 2001, and ending month ________ day ________ year ________ .

A Final return?

Yes. Check applicable box.

IMPORTANT: Your number is required.

California corporation number

Federal employer identification number

Dissolved

Withdrawn

Merged/Reorganized (attach explanation)

___________________________

If a box is checked, enter date

B Check forms filed this year: State:

109

100

100S

Attach Preaddressed Label

Federal:

990

990EZ

990T

990PF

1041

1120H

1120

or See Instructions

C If organization is exempt under R&TC Section 23701d and is a school, public

Corporation/Organization name

charity, religious organization, or is controlled by a religious operation,

check box. See General Instruction F. No filing fee is required.

Address

PMB no.

D Is this a group filing? See General Instruction M. . . . . . . . . . . .

Yes

E Accounting method used ______________________________________________

City

State

ZIP Code

F Type of organization

Exempt under Section 23701 ____ (insert letter)

IRC Section 4947(a)(1) trust

Part I Complete Part I unless not required to file this form. See General Instructions B and C.

1 Gross sales or receipts from other sources. From Side 2, Part II, line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 Gross dues and assessments from members and affiliates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Receipts

3 Gross contributions, gifts, grants, and similar amounts received. See instructions . . . . . . . . . . . . . . . . . . . .

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

and

4 Total gross receipts for filing requirement test. Add line 1 through line 3

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

Revenues

This line must be completed. If the result is less than $25,000, see General Instruction C . . . . . . . . . . . . . .

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

(Attach check

5 Cost of goods sold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

or money

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

6 Cost or other basis, and sales expenses of assets sold . . . . . . . . . . . . . . . . .

order here.)

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

7 Total costs. Add line 5 and line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8 Total gross income. Subtract line 7 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 . . . . . . . . . . . . . . . . . . . . . .

. . . . .

11 Filing fee $10 or $25. See General Instruction F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Filing

. . . . .

Fee

12 Penalty for failure to file on time. See General Instruction L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

. . . . .

13 Balance due. Add line 11 and line 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

14 If exempt under R&TC Section 23701d, has the organization during the year: (1) participated in any political campaign or

(2) attempted to influence legislation or any ballot measure, or (3) made an election under R&TC Section 23704.5 (relating to lobbying

by public charities)? If “Yes,” complete and attach form FTB 3509, Political or Legislative Activities by Section 23701d Organizations . . .

Yes

15 Did the organization have any changes in its activities, governing instrument, articles of incorporation, or bylaws that have not

been reported to the Franchise Tax Board? If “Yes,” complete an explanation and attach copies of revised documents . . . . . . . . . . . . . . . .

Yes

16 Is the organization exempt under R&TC Section 23701g? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If “Yes,” enter amount of gross receipts from nonmember sources $________________________________________________

17 Did the organization file Form 100, Form 100S, or Form 109 to report taxable income? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If “Yes,” enter amount of total income reported $________________________________________

18 The financial records are in care of ______________________________________________________ Daytime telephone (____)___________________

located at __________________________________________________________________________________________________________________

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.

Please

Sign

(

)

Here

Signature of officer

Date

Title

Daytime telephone

Preparer’s SSN or PTIN

Date