Arizona Form 99 - Arizona Exempt Organization Annual Information Return - 2004
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1
22004
ARIZONA FORM
Arizona Exempt Organization Annual Information Return
99
For taxable year beginning
, and ending
CHECK ONE:
Original
Amended
Mail to: Arizona Department of Revenue, PO Box 29079, Phoenix AZ 85038-9079
CHECK ONE:
Calendar year
Fiscal year
Employer identifi cation number (EIN)
Name
Please
AZ withholding tax number
Number and street or PO Box
Type
Business telephone number
or
City or town, state and ZIP code
AZ transaction privilege tax number
Print
FOR DOR USE ONLY
Check box if:
This is a fi rst return
Name change
Address change
A
Date Arizona operations began
B
Nature of Arizona activities _____________________________________________________
C
Check federal form fi led:
990
990-EZ
Other (specify) ___________________
Attach copy of federal return.
81
66
1
Gross sales or receipts from business activities..................................................
1
00
Sources
2
Less: Cost of goods sold or of operations - attach itemized statement ...............
2
00
of
3
Gross profi t from business activities - subtract line 2 from line 1 ........................
3
00
Income
4
Interest.................................................................................................................
4
00
5
Dividends.............................................................................................................
5
00
6
Rents and royalties..............................................................................................
6
00
7
Gain or (loss) from sales of assets, excluding inventory items............................
7
00
8
Dues, assessments, etc., from members ............................................................
8
00
9
Dues, assessments, etc., from affi liated organizations .......................................
9
00
10
Contributions, gifts, grants, etc., received ...........................................................
10
00
11
Other income - attach itemized statement...........................................................
11
00
12
Total income - add lines 3 through 11.................................................................................................................
12
00
13
Compensation of offi cers, directors, trustees, etc. ..............................................
13
00
Administrative
14
Salaries and wages - other than amounts included on line 2 ..............................
14
00
Expenses
15
Interest.................................................................................................................
15
00
16
Taxes ...................................................................................................................
16
00
17
Rent expense ......................................................................................................
17
00
18
Depreciation - attach schedule ............................................................................
18
00
19
Miscellaneous expenses - attach itemized statement .........................................
19
00
20
Total expenses - add lines 13 through 19...........................................................................................................
20
00
Disbursements
21
Dues, assessments, etc., to affi liated corporations .............................................
21
00
from Current
22
Contributions, gifts, grants, etc., paid ..................................................................
22
00
Income for the
23
Benefi t payments to or for members or their dependents:
Organization’s
a. Death, sickness, hospitalization, disability, or pension benefi ts ..................... 23a
00
Exempt
b. Other benefi ts................................................................................................. 23b
00
Purposes
24
Dividends and other distributions to members, shareholders, or depositors.......
24
00
25
Other....................................................................................................................
25
00
26
Total - add lines 21 through 25 ...........................................................................................................................
26
00
Disbursements
27
Dues, assessments, etc., to affi liated corporations .............................................
27
00
from Principal
28
Contributions, gifts, grants, etc., paid ..................................................................
28
00
for the
29
Benefi t payments to or for members or their dependents:
Organization’s
a. Death, sickness, hospitalization, disability, or pension benefi ts ..................... 29a
00
Exempt
b. Other benefi ts................................................................................................. 29b
00
Purposes
30
Dividends and other distributions to members, shareholders, or depositors.......
30
00
31
Other....................................................................................................................
31
00
32
Total - add lines 27 through 31 ...........................................................................................................................
32
00
Other
33
Other disbursements not itemized above - attach schedule...............................................................................
33
00
Accumulation
34
Accumulation of income in current year - line 12 minus the sum of lines 20, 26, 32, and 33.............................
34
00
of Income
35
Accumulation of income at beginning of year.....................................................................................................
35
00
36
Accumulation of income at end of year - add lines 34 and 35............................................................................
36
00
Penalty
37
Penalty for late fi ling or incomplete fi ling ( $500.00 )..........................................................................................
37
00
THE EXEMPT ORGANIZATION IS SUBJECT TO A $500 PENALTY IF THIS RETURN IS FILED LATE OR HAS NOT BEEN COMPLETED. ARS § 42-1125.K
ADOR 91-0022 (04)
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