Section II.
Fee Calculation
9.
Total Revenue ...........................................................................................................................
9.
(From Line 12 (current year) on Form 990; Line 9 on Form 990-EZ; Part I, Line 12a on Form 990-PF; Line 9 on Form 1041;
or see the CT-12 instructions if no federal tax return was prepared or a Form 990-N was filed. Attach explanation if Total
Revenue is $0.)
10.
Revenue Fee ............................................................................................................................................................................
10.
(See chart below. Minimum fee is $20, even if total revenue is a negative amount.)
Amount on Line 9
Revenue Fee
$0
-
$24,999
$20
$25,000
-
$49,999
$50
$50,000
-
$99,999
$90
$100,000
-
$249,999
$150
$250,000
-
$499,999
$200
$500,000
- $1,000,000
$300
$1,000,000
or
more
$400
11.
Net Assets or Fund Balances at End of the Reporting Period ......
11.
(From Line 22 (end of year) on Form 990, Line 21 on Form 990-EZ, or Part III, Line
6 on Form 990-PF; or see the CT-12 instructions to calculate.)
12.
Net Fixed Assets Used to Conduct Charitable Activities ...........
12.
(Generally, from Part X, Line 10c on Form 990, Line 23B on Form 990-EZ or Part
II, Line 14b on Form 990-PF; or see the CT-12 instructions to calculate. See the
Ct-12 instructions if organization owns income-producing assets.)
13.
Amount Subject to Net Assets or Fund Balances Fee ..............................................................
13.
(Line 11 minus Line 12. If Line 11 minus Line 12 is less than $50,000, write $0.)
14.
Net Assets or Fund Balances Fee ...........................................................................................................................................
14.
(Line 13 multiplied by .0001. If the fee is less than $5, enter $0. Not to exceed $2,000. Round cents to the nearest whole dollar.)
Are you filing this report late?
Yes
No.................................................................................................................
15.
15.
(If yes, the late fee is a minimum of $20. You may owe more depending on how late the report is. See Instruction 15 for additional information or contact the
Charitable Activities Section at (971) 673-1880 to obtain late fee amount.)
16.
Total Amount Due ...................................................................................................................................................................
16.
(Add Lines 10, 14, and 15. Make check payable to the Oregon Department of Justice.)
Attach a copy of the organization’s federal 990 or other return and all supporting schedules and attachments that were filed with the IRS, except that
17.
Form 990 & 990EZ filers do not need to attach a copy of their Schedule B. Also, if the organization did not file with the IRS or filed a 990-N, but had
Total Revenue of $50,000 or more, or Net Assets or Fund Balances of $100,000 or more, see the instructions as the organization may be required to
complete certain IRS forms for Oregon purposes only. If the attached return was not filed with the IRS, then mark any such return as “For Oregon
Purposes Only." If your organization files IRS Form 990-N (e-Postcard) please attach a copy or confirmation of its filing.
Under penalties of perjury, I declare that I have examined this return, including all accompanying forms, schedules, and attachments, and
Please
to the best of my knowledge and belief, it is true, correct, and complete.
Sign
⇒
Here
_______________________________________
_____________________
_________________________
Signature of officer
Date
Title
_______________________________________
_______________________________________________________
Officer’s name (printed)
Address
_______________________________________________________
Phone
⇒
Paid
Preparer’s
_______________________________________
_____________________
_________________________
Use Only
Preparer’s signature
Date
Phone
_______________________________________
_______________________________________________________
Preparer’s name (printed)
Address