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Name:

EIN:

AZ Form 99 (2010)

Page 2 of 2

Schedule A - Balance Sheet

(a)

(b)

NOTE: Amounts used in attached schedules and in this column should be end of year amounts.

Beginning of year

End of year

Assets

Cash.........................................................................................................................

A2a Accounts receivable .................................................. A2a

b Less: allowance for doubtful accounts ................... A2b

c Line A2a less line A2b. Enter difference in column (b) ..........................................

00 A2c

A3a Other notes and loans receivable - attach schedule .. A3a

b Less: allowance for doubtful accounts ................... A3b

c Line A3a less line A3b. Enter difference in column (b) ..........................................

00 A3c

Inventories ...............................................................................................................

Investments (securities) - attach schedule ...............................................................

Investments (other) - attach schedule ......................................................................

A7a Land, buildings, and equipment; basis...................... A7a

b Less: accumulated depreciation - attach schedule A7b

c Line A7a less line A7b. Enter difference in column (b) ..........................................

00 A7c

Other assets - describe _____________________________________________

Total assets - add lines A1 through A8 ................................................................

Liabilities

A10 Accounts payable and accrued expenses ...............................................................

00 A10

A11 Mortgages and other notes payable - attach schedule ............................................

00 A11

A12 Other liabilities - describe .........................................................................................

00 A12

A13 Total liabilities - add lines A10 through A12 ........................................................

00 A13

Net Assets

A14 Capital stock or trust principal ..................................................................................

00 A14

A15 Paid-in or capital surplus ..........................................................................................

00 A15

A16 Retained earnings or accumulated income ..............................................................

00 A16

A17 Total net assets - add lines A14 through A16......................................................

00 A17

A18 Total liabilities and net assets - add lines A13 and A17 .....................................

00 A18

Certiﬁ cation

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 a true, correct and complete return, made in good faith, for the taxable year stated pursuant to the income tax laws of the State of Arizona.

Please

Ofﬁ cer’s signature

Date

Title

Sign Here

Paid

Preparer’s

Preparer’s signature

Date

Preparer’s EIN, PTIN or SSN

Use Only

Firm’s name (or preparer’s, if self-employed)