Form 8734 - Support Schedule For Advance Ruling Period
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1
28734
Support Schedule for Advance Ruling Period
Form
Please refer to the separate instructions for assistance in completing this schedule. For
OMB No. 1545-1836
(Rev. January 2004)
additional help, call IRS Exempt Organizations Customer Services toll free at
Department of the Treasury
1-877-829-5500.
Internal Revenue Service
For tax years beginning
, and ending
, 20
Employer identification number
Name of organization
Print
or
Number and street (or P.O. box number if mail is not delivered to street address)
Room/Suite
Telephone number
type.
See
(
)
Specific
City or town, state, and ZIP + 4
Instructions.
E-mail address
(
)
Fax number
● Get Schedule A (Form 990 or 990-EZ), Organization Exempt Under Section 501(c)(3), and its separate Instructions before
Note:
you complete this for m.
● If you did not receive any support for a given year, show financial data for the year by indicating -0- or none.
● Year 1 should reflect support received as of the date legally organized, unless otherwise specified in the
deter mination letter.
● Organizations that filed For m 990 or 990-EZ will be able to use information reported on Schedule A, Part IV-A, to
complete this for m.
(e) Year 1
(f) Total
Calendar year (or fiscal year beginning in)
(a) Year 5
(b) Year 4
(c) Year 3
(d) Year 2
of Years
(See Note
1 through 5
above.)
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 related 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)
from
businesses
acquired
by
the
organization after June 30, 1975
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 a 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
8734
For Paperwork Reduction Act Notice, see page 6 of separate instructions.
Cat. No. 10010S
Form
(Rev. 1-2004)
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