Form 1028 - Application For Recognition Of Exemption Page 4
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44
Form 1028 (Rev. 9-2006)
Page
Part IV
Financial Data (See instructions.)
Complete the Statement of Receipts and Expenditures and Balance Sheets for the current year and for each of the
three immediately preceding years that the organization was in existence.
Statement of Receipts and Expenditures, for period ending
,
.
(If you prepare a statement of receipts and expenditures that is more descriptive and detailed than the statement below, you
may submit that statement instead of this one.)
1
1
Gross dues and assessments from members
2
2
Gross dues and assessments from affiliated organizations
3a
Gross amount derived from activities related to organization’s exempt
3a
purpose (attach schedule)
3b
(
)
3c
b
Less cost of goods sold
4a
4a
Gross amount from other business activities (attach schedule)
4b
(
)
4c
b
Less cost of goods sold
5a
Gross amount received from sale of assets, excluding inventory items
5a
(attach schedule)
5b
(
)
5c
b
Less cost or other basis and sales expense of assets sold (attach schedule)
6
6
Interest, dividends, rents and royalties
7
7
Other receipts (attach schedule)
8
Total receipts—Add lines 1 through 7 in far right column
8
9
9
Compensation of officers, directors, and trustees (attach schedule)
10
10
Other salaries and wages
11
11
Interest
12
12
Rent
13
13
Depreciation and depletion
14
14
Dues and assessments to affiliated organizations
15
15
Other expenditures (see instructions—attach schedule)
16
16
Patronage dividends (see instructions—attach schedule)
17
17
Total expenditures—Add lines 9 through 16
18
Excess of receipts over expenditures (line 8 less line 17)
18
Enter
Beginning date
Ending date
Balance Sheets
dates
19
19
Cash
20
20
Trade notes and accounts receivable (less allowance for bad debts)
21
21
Inventories
22
22
Investments (attach schedule)
23
23
Other current assets (attach schedule)
24
24
Depreciable and depletable assets (less accumulated depreciation/depletion)
25
25
Land (net of any amortization)
26
26
Other assets (attach schedule)
27
Total assets
27
28
28
Accounts payable
29
29
Mortgages, notes, bonds payable in less than one year
30
30
Other current liabilities (attach schedule)
31
31
Mortgages, notes, bonds payable in one year or more
32
32
Other liabilities (attach schedule)
33
Patronage dividends allocated in noncash form, other than capital stock and
33
interest-bearing obligations
34
Per-unit retains allocated in noncash form
34
Number of shares
35
Capital stock (enter numbers at
Number of
end of year):
Issued for
Issued as
shareholders
money
patronage benefits
35a
a
Voting preferred stock
35b
b
Nonvoting preferred stock
35c
c
Voting common stock
35d
d
Nonvoting common stock
36
36
Paid-in or capital surplus
37
37
Retained earnings (attach schedule)
38
(
)
(
)
38
Less cost of treasury stock
39
Total liabilities and capital
39
1028
Form
(Rev. 9-2006)
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