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Indiana Department of Revenue

Form IT-20NP

Indiana Not-For-Profit Organization Income Tax Return

(Do not write above)

State Form 148

For Calendar Year Ending December 31, 2002

Federal Identification Number

(R1/9-02)

or Fiscal Year Beginning ________/_______ 2002 to December 31, 2002

B B

Month / Day

Principal Business Activity Code

Name of Organization

Indiana Taxpayer Identification Number

Number and Street

Indiana County or O.O.S.

Telephone Number

City

State

Zip Code

(

)

Schedule A — Final Related Gross Income Tax Computation of Partially Exempt Organization

for Calendar Year Beginning 1-1-2002, or Fiscal Year Beginning in 2002 through 12-31-2002

Gross Receipts Received

Column A 1.2% High Rate

Column B .3% Low Rate

(Attach Federal Form 990)

1. Membership fees and dues ........................................................................................................

2002

2. Admission charges .....................................................................................................................

3. Interest income ..........................................................................................................................

Final &

4. Commissions ..............................................................................................................................

Short Year

5. Sale of capital assets (including real estate) ............................................................................

6. Receipts for services .................................................................................................................

IT-20NP

7. Rents and leases .........................................................................................................................

8. Contributions .............................................................................................................................

9. Bingo games, raffles, and other gaming receipts (explain on Schedule G) .........................

10. Sale of all tangible personal property from selling at retail including food, beverages,

sundries, etc. ................................................................................................................................

11. Miscellaneous receipts (explain on Schedule G) ......................................................................

12. Total (add lines 1 through 11) ................................................................................................... 12A

12B

13. Nontaxable receipts (explain on Schedule F) ........................................................................... 13A

13B

14. Balance (line 12 less line 13) .....................................................................................................

15. Exemption ($83.33 per month, total from both columns and line 51 of Schedule B

may not exceed $1,000 & limited to number of months in tax period) .............................. 15A

15B

16. Amounts subject to tax (line 14 less line 15). If less than zero, enter zero .........................

17. Enter the amounts from line 16 multiplied by the respective tax rates for each column . 17A

17B

18. Final related gross income tax (add amounts on line 17 columns A and B) ........................................................................

1 8

SUMMARY OF CALCULATIONS FOR TAX PERIOD - Other Taxes and Total Tax Computation

19. Sales/use tax on purchases subject to use tax from Sales/Use Tax Worksheet ........................................................................

1 9

20. Tax on unrelated business income (from Schedule E, line 75) .................................................................................................

2 0

21. Total tax due (add lines 18, 19 and 20) .......................................................................................................................................

Credit for Estimated Tax and Other Payments in Calendar Year 2002

22. Quarterly estimated income tax payments during 2002: 1

Enter total ...

23. Total amount paid with extension $________, and prior year overpayment credit $_______ from tax year ending ______. Enter total ..

24. Other credits that offset income tax applied through 12-31-2002: (Attach proper schedules and complete explanation) .............................

25. Total credits (add lines 22, 23 and 24) .......................................................................................................................................................

26. Balance of tax due (line 21 minus 25; if line 25 is greater than line 21, proceed to lines 27, 29 and 31) .................................................

27. Penalty for the underpayment of income taxes (attach Schedule IT-2220) ...................................................................................................

28. Interest (if payment is made after the original due date, compute interest). Contact the Department for current interest rate ..................

29. Penalty: If paid late, enter 10% of line 26; see instructions. If line 21 is zero enter $10 per day filed past due date ..........................

30. Total payment due (add lines 26, 27, 28 and 29) Make check payable to the Indiana Department of Revenue. Pay in U.S. funds .....

Fiscal year filers must

31. Total overpayment (line 25 minus lines 21, 27, and 29) ........................................................................ 31

carry over refund

32. Amount of line 31 to be refunded to a calendar year taxpayer ............................................................. 32

33. Amount of line 31 to be applied to the taxpayer's following fiscal or taxable year estimated account .........................................................

I authorize the Department to discuss my return with my tax preparer.

Yes

For Dept. Use ONLY

Under penalties of perjury, I declare 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.

Organization's E-mail Address

Signature of Officer

Date

Print or Type Name

Title

Paid Preparer's Name

Preparer's FID, PTIN, or SSN Number