Form 990 - Return Of Organization Exempt From Income Tax - 2017 Page 5
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125
Form 990 (2017)
Page
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V
. . . . . . . . . . . . .
Yes
No
1a Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable
1a
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b Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
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1b
c Did the organization comply with backup withholding rules for reportable payments to vendors and
reportable gaming (gambling) winnings to prize winners? .
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1c
2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax
2a
Statements, filed for the calendar year ending with or within the year covered by this return
b If at least one is reported on line 2a, did the organization file all required federal employment tax returns? .
2b
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions) .
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3a Did the organization have unrelated business gross income of $1,000 or more during the year?
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3a
b If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O .
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3b
4a At any time during the calendar year, did the organization have an interest in, or a signature or other authority
over, a financial account in a foreign country (such as a bank account, securities account, or other financial
account)? .
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4a
b If “Yes,” enter the name of the foreign country:
▶
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts
(FBAR).
5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? .
5a
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b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
c If “Yes” to line 5a or 5b, did the organization file Form 8886-T? .
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5c
6a Does the organization have annual gross receipts that are normally greater than $100,000, and did the
organization solicit any contributions that were not tax deductible as charitable contributions? .
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6a
b If “Yes,” did the organization include with every solicitation an express statement that such contributions or
6b
gifts were not tax deductible? .
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7
Organizations that may receive deductible contributions under section 170(c).
a Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods
and services provided to the payor? .
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7a
b If “Yes,” did the organization notify the donor of the value of the goods or services provided? .
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7b
c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was
required to file Form 8282? .
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7c
d If “Yes,” indicate the number of Forms 8282 filed during the year
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7d
e Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
7e
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? .
7f
g If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?
7g
h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?
7h
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Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the
sponsoring organization have excess business holdings at any time during the year? .
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9
Sponsoring organizations maintaining donor advised funds.
a Did the sponsoring organization make any taxable distributions under section 4966? .
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9a
b Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?
9b
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10
Section 501(c)(7) organizations. Enter:
a Initiation fees and capital contributions included on Part VIII, line 12
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10a
b Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
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10b
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Section 501(c)(12) organizations. Enter:
a Gross income from members or shareholders .
11a
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b Gross income from other sources (Do not net amounts due or paid to other sources
against amounts due or received from them.) .
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11b
12a Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
b If “Yes,” enter the amount of tax-exempt interest received or accrued during the year .
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12b
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a Is the organization licensed to issue qualified health plans in more than one state?
13a
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Note. See the instructions for additional information the organization must report on Schedule O.
b Enter the amount of reserves the organization is required to maintain by the states in which
the organization is licensed to issue qualified health plans
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13b
c Enter the amount of reserves on hand
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13c
14a Did the organization receive any payments for indoor tanning services during the tax year? .
14a
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b If “Yes,” has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O
14b
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990
Form
(2017)
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