Sample Form 990 - Return Of Organization Exempt From Income Tax - 2015 Page 5

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26P0007 10/13/2016 12:54 PM
PHILADELPHIA VETERANS COMFORT HOUSE 23-2694118
5
Form 990 (2015)
Page
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
3
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable
1a
. . . . . . . . . . . . . . . . . . .
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable
1b
. . . . . . . . . . . . . . . .
c
Did the organization comply with backup withholding rules for reportable payments to vendors and
X
reportable gaming (gambling) winnings to prize winners?
1c
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax
1
Statements, filed for the calendar year ending with or within the year covered by this return
2a
. . . .
X
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
2b
. . . . . . . . . . . . . . . . . . . . .
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
X
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?
3a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O
3b
. . . . . . . . . . . . . . . . . . . . . . . .
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority
over, a financial account in a foreign country (such as a bank account, securities account, or other financial
X
account)?
4a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b
If “Yes,” enter the name of the foreign country:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts
(FBAR).
X
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?
5a
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
. . . . . . . . . . . . . . . . . . . .
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T?
5c
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the
X
organization solicit any contributions that were not tax deductible as charitable contributions?
6a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or
gifts were not tax deductible?
6b
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods
X
and services provided to the payor?
7a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?
7b
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was
X
required to file Form 8282?
7c
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d
If “Yes,” indicate the number of Forms 8282 filed during the year
7d
7d
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
7e
. . . . . . . . . . . . . . . . .
X
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
7f
. . . . . . . . . . . . . . . . . . . . .
X
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?
7g
. .
X
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?
7h
8
Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the
sponsoring organization have excess business holdings at any time during the year?
8
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
Sponsoring organizations maintaining donor advised funds.
a
Did the sponsoring organization make any taxable distributions under section 4966?
9a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b
Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?
9b
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12
10a
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
. . . . . . . . .
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders
11a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b
Gross income from other sources (Do not net amounts due or paid to other sources
against amounts due or received from them.)
11b
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
. . . . . . . . . . . . . . . . .
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year
12b
. . . . . . . . . .
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
13a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Note. See the instructions for additional information the organization must report on Schedule O.
b
Enter the amount of reserves the organization is required to maintain by the states in which
the organization is licensed to issue qualified health plans
13b
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c
Enter the amount of reserves on hand
13c
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
14a Did the organization receive any payments for indoor tanning services during the tax year?
14a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14b
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O
. . . . . . . . . . . . . . . . . . . . . .
990
DAA
Form
(2015)

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