Fillable Form 8734 - Support Schedule For Advance Ruling Period printable pdf download

8734

Department of the Treasury - Internal Revenue Service

Form

Support Schedule For Advance Ruling Period

(Revised January 2002)

Employer Identification Number

Name of Organization

For information on completing this support schedule, refer to the instructions for Form 990 (Schedule A, Part IV), or call TE/GE Customer Account Services

at 877-829-5500 between the hours of 8:00 a.m. and 6:30 p.m. Eastern Time, Monday through Friday.

NOTE: If you did not receive any support for a given year, please be sure to show financial data for that year by indicating -0- or -none. Year 1 should reflect support

received as of the date legally organized, unless otherwise specified in the determination letter.

Year 1

Year 2

Year 3

Year 4

Year 5

TOTAL

1. Gifts grants and contributions received. (Do not include unusual grants. See

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

line 14)

2. Membership fees received. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Gross receipts from admissions, merchandise sold or services performed, or

furnishing of facilities in any activity that is not a business unrelated to the

organization's charitable, etc, purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Gross income from interest, dividends, amounts received from payments on

securities loans (section 512(a)(5)), rents, royalties, and unrelated business taxable

income (less section 511 taxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Net income from unrelated business activities not included in line 4. . . . . . .

6. Tax revenues levied for your benefit and either paid to you or expended on your

behalf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. The value of services or facilities furnished to you by a governmental unit without

charge. Do not include the value of services or facilities generally furnished to the

public without charge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. Other income. Attach schedule. Do not include gain (or loss) from sale of capital

assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. Total of lines 1 through 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. Line 9 minus line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11. Enter 1% of line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12. Organizations described in section 170(b)(1)(A)(vi):

a. Enter 2% of amount shown in TOTAL column, line 10 **

b. For all years, did total contributions from any person other than a governmental unit or publicly supported organization exceed the amount shown on line 12a?

Yes

If yes, attach a list showing the name of and amount contributed by each person whose total gifts exceeded the 2% amount. If available, please list the contributing organization's

Employer Identification Number (EIN).

Catalog Number 10010S (Page 1 of 2)

Form 8734 - Support Schedule For Advance Ruling Period

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