Form 199 - California Exempt Organization Annual Information Return - 2009
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1
2California Exempt Organization
TAXABLE YEAR
FORM
199
2009
Annual Information Return
Calendar Year 2009 or fiscal year beginning month _______ day _______ year _______, and ending month _______ day _______ year _______ .
B Type of organization
A First Return Filed?
CORP #
Yes
Exempt under Section 23701 ____ (insert letter)
No
IRC Section 4947(a)(1) trust
Corporation/Organization Name
FEIN
-
Address
City
State
ZIP Code
C Amended Return? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
check box. See General Instruction F. No filing fee is required. . . . . . . . . . . . . . . . . . .
D Are you a subordinate/affiliate in a group exemption? . . . . . . . . . . . . . . . . . . .
Yes
No
H Accounting method used (1)
Cash (2)
Accrual (3)
Other
(a) Is this a group filing for affiliates? See General Instruction L . . . . . .
Yes
No
If exempt under R&TC Section 23701d, has the organization during the year: (1) participated
I
(b) If “Yes,” enter the number of affiliates . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________
in any political campaign or (2) attempted to influence legislation or any ballot measure, or
(c) Are all affiliates included? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
(3) made an election under R&TC Section 23704.5 (relating to lobbying by public charities)?
(If “No,” attach a list. See instructions.)
If “Yes,” complete and attach form FTB 3509, Political or Legislative Activities by Section
(d) Is this a separate return filed by an organization covered by a
23701d Organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
group ruling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
J Did the organization have any changes in its activities, governing instrument, articles of
(e) Federal Group Exemption Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________
incorporation, or bylaws that have not been reported to the Franchise Tax Board? If “Yes,”
(f) Is a roster of subordinates attached? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
complete an explanation and attach copies of revised documents . . . . . . .
Yes
No
E Final return?
K Is the organization exempt under R&TC Section 23701g? . . . . . . . . . . . . .
Yes
No
Dissolved
Surrendered (Withdrawn)
If “Yes,” enter amount of gross receipts from nonmember sources $____________________
Merged/Reorganized (attach explanation)
L Is the organization under audit by the IRS or has the IRS audited in
___________________________
If a box is checked, enter date
a prior year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
:
Check the box if the organization filed the following federal forms or schedule
M Is the organization a Limited Liability Company? . . . . . . . . . . . . . . . . . . .
Yes
No
F
(1)
990T (2)
990PF (3)
(Schedule H) 990
N Did the organization file Form 100 or Form 109 to report taxable
G If organization is exempt under R&TC Section 23701d and is exclusively religious,
income? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
educational, or charitable, and is supported primarily (50% or more) by public contributions,
Part I Complete Part I unless not required to file this form. See General Instructions B and C.
1 Gross sales or receipts from other sources. From Side 2, Part II, line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
00
00
2 Gross dues and assessments from members and affiliates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Receipts
00
3 Gross contributions, gifts, grants, and similar amounts received. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
and
4 Total gross receipts for filing requirement test. Add line 1 through line 3.
Revenues
00
This line must be completed. If the result is less than $25,000, see General Instruction C. . . . . . . . . . . . . . . . .
4
00
5 Cost of goods sold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
00
6 Cost or other basis, and sales expenses of assets sold . . . . . . . . . . . . . . . . . .
6
00
7 Total costs. Add line 5 and line 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
00
8 Total gross income. Subtract line 7 from line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
9 Total expenses and disbursements. From Side 2, Part II, line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
00
Expenses
00
10 Excess of receipts over expenses and disbursements. Subtract line 9 from line 8 . . . . . . . . . . . . . . . . . . . . . . . .
10
11 Filing fee $10 or $25. See General Instruction F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
00
00
12 Total payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
Filing
Fee
00
13 Penalties and Interest. See General Instruction J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
00
14 Use tax. See General Instruction K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
00
15 Balance due. Add line 11, line 13, and line 14. Then subtract line 12 from the result . . . . . . . . . . . . . . . . . . . . . .
15
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
Sign
true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here
Title
Date
Telephone
Signature
(
)
of officer
Date
Preparer’s SSN/PTIN
Check if self-
Preparer’s
employed
Paid
signature
Preparer’s
FEIN
-
Use Only
Firm’s name (or yours,
if self-employed)
Telephone
and address
(
)
May the FTB discuss this return with the preparer shown above? See instructions . . . . . . . . . . . . . . . . . .
Yes No
3651093
Form 199
2009 Side 1
C1
For Privacy Notice, get form FTB 1131.
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