Arizona Form 99 - Arizona Exempt Organization Annual Information Return - 2012

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ARIZONA FORM
2012
Arizona Exempt Organization Annual Information Return
99
For the
calendar year 2012 or
fi scal year beginning
and ending
.
M M D D Y Y Y Y
M M D D Y Y Y Y
CHECK ONE:
Name
Employer identification number (EIN)
Please
Original
Amended
Type
Number and street or PO Box
Business telephone number
AZ transaction privilege tax number
or
(with area code)
City or town, state and ZIP code
Print
CHECK BOX IF: Return filed under extension.
68 Check box if:
This is a first return
Name change
Address change
3-mos. Fed
6-mos. AZ - Fed
M M D D Y Y Y Y
A
Date Arizona operations began:
82
C
F
82
82
B
Nature of Arizona activities:
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
C
Federal form filed:
990
990-EZ
Other (specify)
Attach a copy of the organization’s federal return.
Nonprofit Medical Marijuana Dispensary (NMMD) only:
D
NMMD Registry Identification Number:
E
What type of entity is the dispensary?
Corporation
Limited Liability Company (LLC)
Partnership
S corporation
Sole Proprietorship
81
66
F
If the dispensary is an LLC, what is the federal tax classification?
Corporation
Disregarded Entity
Partnership
S corporation
If the dispensary is an LLC, a partnership or an S corporation, attach a schedule that lists ownership information including name, address, TIN,
and ownership percentage at the end of the tax year.
G Federal form filed:
1040
1041
1065
1120
1120-S
Other (specify)
H
Check this box if you attached a copy of the dispensary’s federal return to its Arizona Form 120S or Form 165 when it was filed; do not attach a
copy of the same return to this form. Otherwise, attach a copy of the dispensary’s federal return.
Sources of Income
00
1 Gross sales from business activities ........................................................................................
1
00
2 Less: Cost of goods sold or of operations – attach itemized statement ..................................
2
00
3 Gross profit from business activities – subtract line 2 from line 1 ............................................
3
00
4 Interest .....................................................................................................................................
4
00
5 Dividends .................................................................................................................................
5
00
6 Rents and royalties ..................................................................................................................
6
00
7 Gain or (loss) from sales of assets, excluding inventory items ................................................
7
00
8 Dues, assessments, etc., from members ................................................................................
8
00
9 Dues, assessments, etc., from affiliates ..................................................................................
9
00
10 Contributions, gifts, grants, etc., received ................................................................................
10
00
11 Other income – attach itemized statement ..............................................................................
11
00
12 Total income – add lines 3 through 11 ............................................................................................................................
12
Administrative Expenses
00
13 Compensation of officers, directors, trustees, etc. ...................................................................
13
00
14 Salaries and wages – other than amounts included on line 2 .................................................
14
00
15 Interest .....................................................................................................................................
15
00
16 Taxes .......................................................................................................................................
16
00
17 Rent expense ...........................................................................................................................
17
00
18 Depreciation – attach schedule ...............................................................................................
18
00
19 Miscellaneous expenses – attach itemized statement .............................................................
19
00
20 Total expenses – add lines 13 through 19 ......................................................................................................................
20
Disbursements
00
21 Disbursements from current income for exempt purposes – from page 2, line A6 .........................................................
21
00
22 Disbursements from principal for exempt purposes – from page 2, line B6 ...................................................................
22
00
23 Other disbursements not itemized on Schedule A or Schedule B – attach schedule .....................................................
23
Accumulation of Income
00
24 Accumulation of income in current year – line 12 less the sum of lines 20, 21, 22, and 23 ...........................................
24
00
25 Accumulation of income at beginning of year .................................................................................................................
25
00
26 Accumulation of income at end of year – add lines 24 and 25 .......................................................................................
26
Penalty
00
27 Penalty for late filing or incomplete filing. See instructions ............................................................................................
27
THE BUSINESS IS SUBJECT TO A PENALTY IF THIS RETURN IS FILED LATE OR IS INCOMPLETE. ARS § 42-1125(K).
ADOR 10418 (12)
Continued on page 2

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