S
T
: R
A
R
O
ECTION
HREE
EQUIRED FOR
NNUAL
EPORTING
NLY
All annual report filers must complete questions 1 2, 3 and 4.
1.
List the five highest paid directors, officers and employees of the organization and its related
organization(s) who receive total compensation of $50,000 or more, indicating their titles and total
compensation paid to each.
Total compensation includes salaries, fees, bonuses, fringe benefits,
severance payments and deferred compensation paid by the organization and all related organizations. A
“related organization” is an organization that controls, is controlled by or is under common control with
another corporation. “Control” can exist through stock ownership or membership interests, the authority
to appoint members, or the ability to direct the policies and management of other corporations. See Minn.
Stat. § 317A.011, subd. 18.
Name/Title
Compensation
1
2
3
4
5
2.
Attach a GAAP audit if total revenue exceeds $750,000.
Attached
Audit not included under the Food Shelf Exemption (excluding from total revenue the value of
food donated to a nonprofit food shelf for redistribution at no cost).
Audit not required
3.
Minnesota law requires that an organization file a copy of any IRS Form 990-N (e-Postcard), 990, 990-EZ,
or 990-PF informational return that was filed with the IRS. Has the organization included with this annual
report a copy of all IRS Form 990-N (e-Postcard), 990, 990-EZ or 990-PF informational returns that it
filed with the IRS (excluding Schedule B or any other donor list required by the IRS)?
Yes
No (Not required to file a return with IRS or files with National Chapter).
NOTE: By answering YES to the above question, you are attesting that the IRS informational return filed
with this office is an exact copy, including all schedules and attachments, of the IRS informational return
filed with the IRS (excluding Schedule B or any other donor list the IRS may require).
2
1
2
3
4
