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SCHEDULE A

NYS BOARD OF REAL PROPERTY SERVICES

RP-420-a/b-Rnw-I (1/95)

RENEWAL APPLICATION FOR REAL PROPERTY TAX

EXEMPTION FOR NONPROFIT ORGANIZATIONS

I-ORGANIZATION PURPOSE

_____________________________________

1a. Name of Organization

c. Employer ID no.

_____________________________________

d. Name of contact person

_____________________________________

b. Mailing address

e. Day telephone no. of contact person

_____________________________________

f. Evening telephone no.

2a. Statement of receipts and expenditures for the fiscal year (year ending ___________________, 20_______)

RECEIPTS

(1) Gross dues and assessments of members .........................................................................................

(2) Gross contributions, gifts, etc. * .....................................................................................................

(3) Gross amounts derived from activities related to organization’s

exempt purpose (attach schedule) ...........................................................

Less cost of sales (attach schedule) ............................................

(4) Gross amount from unrelated business activities (attach schedule)...

Less cost of sales (attach schedule) ............................................

(5) Gross amounts received from sale of assets, excluding inventory

items (attach schedule) ............................................................................

Less cost or other basis and sales expenses of assets sold (attach

schedule) ..................................................................................................

(6) Interest, dividends, rents and royalties .............................................................................................

(7) Other receipts (attach schedule) .......................................................................................................

(8) Total receipts .....................................................................................................................................

EXPENDITURES

(9) Fund raising expenses ......................................................................................................................

(10) Contributions, gifts, grants and similar amounts paid (attach schedule) ........................................

(11) Disbursements to or for the benefit of members (attach schedule) ................................................

(12) Compensation of officers, directors and trustees ...........................................................................

(13) Other salaries and wages ...............................................................................................................

(14) Interest ...........................................................................................................................................

(15) Rent ...............................................................................................................................................

(16) Depreciation and depletion ............................................................................................................

(17) Other expenditures (attach schedule) .............................................................................................

(18) TOTAL EXPENDITURES ...........................................................................................................

(19) Excess of receipts over expenditures (line 8 less line 18) ..............................................................

*If the organization received any unusual grants during the year, attach a list showing the name of the contributor, the date and amount of the

grant and a brief description of the nature of the grant.

Form Rp-420-A/b-Rnw-I - Schedule A - Renewal Application For Real Property Tax Exemption For Nonprofit Organizations I-Organization Purpose

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