Irs 8734 Form – Fill Out and Use This PDF

For tax years beginning		, and ending			,	20
	Name of organization			Employer identification number
Print
or
type.	Number and street (or P.O. box number if mail is not delivered to street address)		Room/Suite	Telephone number
See				(	)
Specific
	City or town, state, and ZIP + 4
Instructions.				E-mail address
				Fax number (		)

Note: ● Get SCHEDULE A (FORM 990 OR 990-EZ), Organization Exempt Under Section 501(c)(3), and its separate Instructions before 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 infor mation 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	(See Note	of Years
					above.)	1 through 5

1 Gifts, grants, and contributions received. (Do not include unusual grants. See line 14.)

2Membership fees received

3Gross 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

5Net income from unrelated business activities not included in line 4

6Tax revenues levied for your benefit and either paid to you or expended on your behalf

7The 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

8Other income. Attach a schedule. Do not include gain (or loss) from sale of capital assets

9Total of lines 1 through 8

10 Line 9 minus line 3

11 Enter 1% of line 9

For Paperwork Reduction Act Notice, see page 6 of separate instructions.

Cat. No. 10010S

Form 8734 (Rev. 1-2004)

Form 8734 (Rev. 1-2004)

Page 2

12If you are an organization that normally receives a substantial part of your support from a governmental unit or from the general public, complete lines 12a through 12f. (Sections 509(a)(1) and 170(b)(1)(A)(vi)). If you want the IRS to compute your public support test as a section 509(a)(1) and 170(b)(1)(A)(vi) organization, complete only lines 12a and 12b.

13If you are an organization that normally receives: (1) more than 331⁄3% of your support from contributions, membership fees, and gross receipts from activities related to your exempt functions, and (2) no more than 331⁄3% of your support from gross investment income and net unrelated business taxable income from businesses acquired by the organization after June 30, 1975, complete lines 13a through 13h. (Section 509(a)(2)). If you want the IRS to compute your public support test as a section 509(a)(2) organization, complete only lines 13a and 13b.

aFor amounts included in lines 1, 2, and 3 that were received from a “disqualified person,” attach a list showing the name of, and total amounts received in each year from, each “disqualified person.” Enter the sum of such amounts for each year:

(Year 5)

(Year 4)

(Year 3)

(Year 2)

(Year 1)

bFor any amount included in line 3 that was received from each person (other than “disqualified persons”), attach a list showing the name of, and amount received for each year, that was more than the larger of (1) the amount on line 11 for the year or

(2) $5,000. (Include in the list organizations as well as individuals.) After computing the difference between the amount received and the larger amount described in (1) or (2), enter the sum of these differences (the excess amounts) for each year:

	(Year 5)	(Year 4)	(Year 3)	(Year 2)			(Year 1)
c	Add: Amounts from column (f) for lines:		1	2
		3	6	7				13c
d	Add: Line 13a total		and line 13b total					13d
e	Public support (line 13c total minus line 13d total)							13e
f	Total support for section 509(a)(2) test: Enter amount from line 9, column (f)					13f
g	Public support percentage (line 13e (numerator) divided by line 13f (denominator))							13g	%
h	Investment income percentage (line 4, column (f) (numerator) divided by line 13f (denominator))							13h	%

14Unusual Grants: For an organization described in line 12 or 13 that received any unusual grants during Year 5 through Year 1, attach a list showing for each year the name of the contributor, the date and amount of the grant, and a brief description of the nature of the grant. Do not include these grants in line 1.

List the amount of unusual grants excluded for each year below.

(Year 5)

(Year 4)

(Year 3)

(Year 2)

(Year 1)

15Please list the name and telephone number of an officer, director, or trustee who can be contacted during business hours if we need more information. If someone other than an officer, director, or trustee will represent the organization, attach a properly completed Form 2848, Power of Attorney.

Name:

Type or print name and title.

Phone:

(

)

Fax Number (if available):

(

)

I declare under the penalties of perjury that I am authorized to sign this form on behalf of the above organization and that I have examined this form, including the accompanying attachments, and to the best of my knowledge it is true, correct, and complete.

	Please
	Sign
		Signature of officer, director, or trustee		Date
	Here
			Type or print name and title or authority of signer

Form 8734 (Rev. 1-2004)