Form 1024-A - Application For Recognition Of Exemption Page 3
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Form 1024-A (1-2018)
Name:
EIN:
Page
Part VI
Financial Data (see instructions for information you must provide) (attach statement regarding accounting
method, if necessary)
A. Statement of Revenues and Expenses
Type of revenue or expense
Year:
Year:
Year:
1 Gifts, grants, and contributions received
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2 Membership fees received .
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3 Gross investment income
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4 Net unrelated business income
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5 Taxes levied for your benefit
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6 Value of services or facilities furnished by a governmental unit
without charge .
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7 Any revenue not otherwise listed above or in lines 9–11 below
(attach statement) .
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8 Total of lines 1 through 7
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9 Gross receipts from any activity that is related to your exempt
purposes
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10 Total of lines 8 and 9 .
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11 Net gain or loss on sale of capital assets (attach statement) .
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12 Total Revenue
Combine lines 10 and 11
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13 Fundraising expenses (attach statement) .
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14 Contributions, gifts, grants, and similar amounts paid out (attach
statement)
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15 Disbursements to or for the benefit of members (attach statement) .
16 Compensation of officers, directors, and trustees
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17 Other salaries and wages
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18 Occupancy .
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19 Any expense not otherwise classified, such as program services
(attach statement) .
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20 Total Expenses
Add lines 13 through 19 .
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B. Balance Sheet (for your most recently completed tax year)
Year End
Assets
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1
Cash
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2
Accounts receivable, net .
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Inventories
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3
4
Bonds and notes receivable (attach statement)
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5
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Corporate stocks (attach statement) .
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Loans receivable (attach statement) .
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7
Other investments (attach statement) .
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Depreciable and depletable assets (attach statement) .
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9
Land
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9
10
Other assets (attach statement)
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10
11
11
Total assets (add lines 1 through 10) .
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Liabilities
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Accounts payable .
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12
13
13
Contributions, gifts, grants, etc., payable
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14
14
Mortgages and notes payable (attach statement) .
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15
Other liabilities (attach statement) .
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15
16
Total liabilities (add lines 12 through 15) .
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16
Fund Balances or Net Assets
17
Total fund balances or net assets .
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17
18
Total liabilities and fund balances or net assets (add lines 16 and 17) .
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1024-A
Form
(1-2018)
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