Arizona Form 99 - Arizona Exempt Organization Annual Information Return - 2014
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1
2
3Arizona Form
2014
Arizona Exempt Organization Annual Information Return
99
For the
calendar year 2014 or
fiscal year beginning
M M D D
2 0 1 4 and ending
M M D D
2 0
Y Y
.
CHECK ONE:
Name
Employer Identification Number (EIN)
Original
Address – number and street or PO Box
Amended
Business Telephone Number
(with area code)
City, Town or Post Office
State
ZIP Code
CHECK BOX IF return filed under extension:
68 Check box if:
This is a first return
Name change
Address change
82
C
3-month federal
M M D D Y Y Y Y
82
A
Date Arizona operations began:
F
6-month Arizona/federal
82
B
Nature of Arizona activities:
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
C Federal form filed:
990
990-EZ
Other (specify)
88
Include a copy of the organization’s federal return.
NONPROFIT MEDICAL MARIJUANA DISPENSARY (NMMD) ONLY –
D
N MMD Registry Identification Number:
E
What type of entity is the dispensary?
C orporation
Limited Liability Company (LLC)
Partnership
S corporation
81 PM
66 RCVD
Sole Proprietorship
F
If the dispensary is an LLC, what is the federal tax classification?
C orporation
Disregarded Entity
Partnership
S corporation
If the dispensary is an LLC, a partnership or an S corporation, include a schedule that lists the following ownership information:
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
C heck this box if you included a copy of the dispensary’s federal return with its Arizona Form 120S or Form 165 when it was filed;
do not include a copy of the same return with this form. Otherwise, include 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: Include 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: Include 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: Include schedule ............................................................................................ 18
00
19 Miscellaneous expenses: Include 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: Include 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. A.R.S. § 42-1125(K).
ADOR 10418 (14)
Continued on page 2
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