Form 199 - California Exempt Organization Annual Information Return - 2011
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1
2California Exempt Organization
TAXABLE YEAR
FORM
199
2011
Annual Information Return
Calendar Year 2011 or fiscal year beginning month _______ day _______ year _______, and ending month _______ day _______ year _______ .
Corporation/Organization Name
California corporation number
Address (suite, room, or PMB no.)
FEIN
-
City
State
ZIP Code
J If exempt under R&TC Section 23701d, has the organization
A First Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
during the year: (1) participated in any political campaign,
B Amended Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
or (2) attempted to influence legislation or any ballot measure,
C IRC Section 4947(a)(1) trust . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
or (3) made an election under R&TC Section 23704.5
D Final Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
(relating to lobbying by public charities)? . . . . . . . . . . . . . .
Yes
No
Dissolved
Surrendered (Withdrawn)
If “Yes,” complete and attach form FTB 3509.
Merged/Reorganized Enter date:
____ / _____ / _______
K Is the organization exempt under R&TC Section 23701g? .
Yes
No
E Check accounting method:
If “Yes,” enter the gross receipts from nonmember
(1)
Cash (2)
Accrual (3)
Other
sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ____________
F Federal return filed?
L If organization is exempt under R&TC Section 23701d and is
(1)
990T (2)
990(PF) (3)
Sch H (990)
exclusively religious, educational, or charitable, and is
G Is this a group filing for the subordinates/affiliates? . . . . . .
Yes
No
supported primarily (50% or more) by public contributions,
If “Yes,” attach a roster. See instructions
check box. No filing fee is required. . . . . . . . . . . . . . . . . . .
H Is this organization in a group exemption? . . . . . . . . . . . . . .
Yes
No
M Is the organization a Limited Liability Company? . . . . . . . .
Yes
No
If “Yes,” what is the parent’s name?
N Did the organization file Form 100 or Form 109 to report
________________________________________________
taxable income? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
I Did the organization have any changes in its activities,
O Is the organization under audit by the IRS or has the
governing instrument, articles of incorporation, or bylaws
IRS audited in a prior year? . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
that have not been reported to the Franchise Tax Board? . .
Yes
No
If “Yes,” explain, and attach copies of revised documents.
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 B. . . . . . . . . . . . . . . . .
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
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
Form 199
2011 Side 1
3651113
C1
For Privacy Notice, get form FTB 1131.
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