North Myrtle Beach, SC Phone no May the IRS discuss this return with the preparer shown above? (see instructions)...

Transcription

1 // : PM Form Unr stion (),, or ()() of th Intrnl Rvnu Co (xpt privt fountions) Dprtmnt of th Trsury u Do not ntr soil surity numrs on this form s it my m puli. Intrnl Rvnu Srvi u Go to for instrutions n th ltst informtion. A For th lnr yr, or tx yr ginning, n ning B I J K Ativitis & Govrnn Rvnu Expnss Nt Assts or Fun Blns Chk if pplil: Arss hng Nm hng Initil rturn Finl rturn/ trmint Amn rturn Applition pning Tx-xmpt sttus: Wsit: u Form of orgniztion: Prt I C Nm of orgniztion F Doing usinss s Rturn of Orgniztion Exmpt From Inom Tx Numr n strt (or P.O. ox if mil is not livr to strt rss) City or town, stt or provin, ountry, n ZIP or forign postl o Nm n rss of prinipl offir: Summry () ( ) t (insrt no.) ()() or Grnts n similr mounts pi (Prt I, olumn (A), lins ).. Bnfits pi to or for mmrs (Prt I, olumn (A), lin ) Slris, othr ompnstion, mploy nfits (Prt I, olumn (A), lins ) Profssionl funrising fs (Prt I, olumn (A), lin ) Totl funrising xpnss (Prt I, olumn (D), lin ) u , Othr xpnss (Prt I, olumn (A), lins, f ) Totl xpnss. A lins (must qul Prt I, olumn (A), lin ) Room/suit E Tlphon numr G Gross ripts $ OMB. - Opn to Puli Insption D Employr intifition numr H() Is this group rturn for suorints? H() Ar ll suorints inlu? If "," tth list. (s instrutions) H() Group xmption numr u Corportion Trust Assoition Othr u L Yr of formtion: M Stt of lgl omiil: Brifly sri th orgniztion's mission or most signifint tivitis: Chk this ox u if th orgniztion isontinu its oprtions or ispos of mor thn % of its nt ssts. Numr of voting mmrs of th govrning oy (Prt VI, lin )... Numr of inpnnt voting mmrs of th govrning oy (Prt VI, lin ) Totl numr of iniviuls mploy in lnr yr (Prt V, lin ) Totl numr of voluntrs (stimt if nssry) Totl unrlt usinss rvnu from Prt VIII, olumn (C), lin. Nt unrlt usinss txl inom from Form -T, lin..... Prior Yr PO Box Humn Soity of rth Myrtl Bh In. rth Myrtl Bh SC - VICKI BLAIR NORTH POPLAR DRIVE SURFSIDE BEACH SC ()() THE HUMANE TREATMENT OF ANIMALS Contriutions n grnts (Prt VIII, lin h) Progrm srvi rvnu (Prt VIII, lin g) Invstmnt inom (Prt VIII, olumn (A), lins,, n ) Othr rvnu (Prt VIII, olumn (A), lins,,,,, n ) Totl rvnu lins through (must qul Prt VIII, olumn (A), lin ) Rvnu lss xpnss. Sutrt lin from lin Totl ssts (Prt, lin ) Totl liilitis (Prt, lin ) Nt ssts or fun lns. Sutrt lin from lin Prt II Signtur Blok Bginning of Currnt Yr - Currnt Yr En of Yr Unr pnltis of prjury, I lr tht I hv xmin this rturn, inluing ompnying shuls n sttmnts, n to th st of my knowlg n lif, it is tru, orrt, n omplt. Dlrtion of prprr (othr thn offir) is s on ll informtion of whih prprr hs ny knowlg.,,,,,,,,,,,,,,,,,,,,, Sign Hr Pi Prprr Us Only Signtur of offir Typ or print nm n titl Print/Typ prprr's nm Dvi Smith Brittny Johnson } For Pprwork Rution At ti, s th sprt instrutions. BOD Trsurr Prprr's signtur Dt Chk if PTIN Firm's nm Firm's EIN } Dt slf-mploy rth Myrtl Bh, SC - Phon no. -- Firm's rss } My th IRS isuss this rturn with th prprr shown ov? (s instrutions).... P Dvi Smith Assoits, CPA's - th Av S

2 Pg Prt III Sttmnt of Progrm Srvi Aomplishmnts Brifly sri th orgniztion's mission: Di th orgniztion unrtk ny signifint progrm srvis uring th yr whih wr not list on th prior Form or -EZ? If "," sri ths nw srvis on Shul O. Di th orgniztion s onuting, or mk signifint hngs in how it onuts, ny progrm srvis? If "," sri ths hngs on Shul O. Dsri th orgniztion's progrm srvi omplishmnts for h of its thr lrgst progrm srvis, s msur y xpnss. Stion ()() n ()() orgniztions r rquir to rport th mount of grnts n llotions to othrs, th totl xpnss, n rvnu, if ny, for h progrm srvi rport. (Co: ) (Expnss $ inluing grnts of $ ) (Rvnu $ ) ) $ (Rvnu ) $ inluing grnts of $ ) (Expnss (Co: (Co: $ inluing grnts of $ ) ) (Expnss $ ) (Rvnu. Othr progrm srvis (Dsri in Shul O.) (Rvnu ) $ (Expnss ) $ inluing grnts of $ Totl progrm srvi xpnss u Chk if Shul O ontins rspons or not to ny lin in this Prt III. Humn Soity of rth Myrtl - THE HUMANE TREATMENT OF ANIMALS, CARE FOR AND ADOPTION OF ABANDONED ANIMALS, LICENSING FEES & LEASH LAW FINES APPLICABLE TO ANIMALS BROUGHT IN BY CITY ANIMAL CONTROL, // : PM

3 // : PM Prt IV Chklist of Rquir Shuls f Humn Soity of rth Myrtl - Is th orgniztion sri in stion ()() or ()() (othr thn privt fountion)? If, omplt Shul A Is th orgniztion rquir to omplt Shul B, Shul of Contriutors (s instrutions)? Di th orgniztion ngg in irt or inirt politil mpign tivitis on hlf of or in opposition to nits for puli offi? If, omplt Shul C, Prt I Stion ()() orgniztions. Di th orgniztion ngg in loying tivitis, or hv stion (h) ltion in fft uring th tx yr? If "," omplt Shul C, Prt II.... Is th orgniztion stion ()(), ()(), or ()() orgniztion tht rivs mmrship us, ssssmnts, or similr mounts s fin in Rvnu Prour -? If "," omplt Shul C, Prt III Di th orgniztion mintin ny onor vis funs or ny similr funs or ounts for whih onors hv th right to provi vi on th istriution or invstmnt of mounts in suh funs or ounts? If, omplt Shul D, Prt I. Di th orgniztion riv or hol onsrvtion smnt, inluing smnts to prsrv opn sp, th nvironmnt, histori ln rs, or histori struturs? If, omplt Shul D, Prt II Di th orgniztion mintin olltions of works of rt, historil trsurs, or othr similr ssts? If, omplt Shul D, Prt III Di th orgniztion rport n mount in Prt, lin, for srow or ustoil ount liility, srv s ustoin for mounts not list in Prt ; or provi rit ounsling, t mngmnt, rit rpir, or t ngotition srvis? If, omplt Shul D, Prt IV Di th orgniztion, irtly or through rlt orgniztion, hol ssts in tmporrily rstrit nowmnts, prmnnt nowmnts, or qusi-nowmnts? If, omplt Shul D, Prt V..... If th orgniztion's nswr to ny of th following qustions is, thn omplt Shul D, Prts VI, VII, VIII, I, or s pplil. Di th orgniztion rport n mount for ln, uilings, n quipmnt in Prt, lin? If "," omplt Shul D, Prt VI Di th orgniztion rport n mount for invstmnts othr suritis in Prt, lin tht is % or mor of its totl ssts rport in Prt, lin? If "," omplt Shul D, Prt VII... Di th orgniztion rport n mount for invstmnts progrm rlt in Prt, lin tht is % or mor of its totl ssts rport in Prt, lin? If "," omplt Shul D, Prt VIII... Di th orgniztion rport n mount for othr ssts in Prt, lin tht is % or mor of its totl ssts rport in Prt, lin? If "," omplt Shul D, Prt I Di th orgniztion rport n mount for othr liilitis in Prt, lin? If "," omplt Shul D, Prt Di th orgniztion's sprt or onsolit finnil sttmnts for th tx yr inlu footnot tht rsss th orgniztion's liility for unrtin tx positions unr FIN (ASC )? If "," omplt Shul D, Prt Di th orgniztion otin sprt, inpnnt uit finnil sttmnts for th tx yr? If, omplt Shul D, Prts I n II Ws th orgniztion inlu in onsolit, inpnnt uit finnil sttmnts for th tx yr? If "," n if th orgniztion nswr "" to lin, thn omplting Shul D, Prts I n II is optionl Is th orgniztion shool sri in stion ()()(A)(ii)? If, omplt Shul E Di th orgniztion mintin n offi, mploys, or gnts outsi of th Unit Stts? Di th orgniztion hv ggrgt rvnus or xpnss of mor thn $, from grntmking, funrising, usinss, invstmnt, n progrm srvi tivitis outsi th Unit Stts, or ggrgt forign invstmnts vlu t $, or mor? If, omplt Shul F, Prts I n IV Di th orgniztion rport on Prt I, olumn (A), lin, mor thn $, of grnts or othr ssistn to or for ny forign orgniztion? If, omplt Shul F, Prts II n IV.... Di th orgniztion rport on Prt I, olumn (A), lin, mor thn $, of ggrgt grnts or othr ssistn to or for forign iniviuls? If, omplt Shul F, Prts III n IV.. Di th orgniztion rport totl of mor thn $, of xpnss for profssionl funrising srvis on Prt I, olumn (A), lins n? If, omplt Shul G, Prt I (s instrutions) Di th orgniztion rport mor thn $, totl of funrising vnt gross inom n ontriutions on Prt VIII, lins n? If "," omplt Shul G, Prt II Di th orgniztion rport mor thn $, of gross inom from gming tivitis on Prt VIII, lin? If "," omplt Shul G, Prt III f Pg

4 // : PM Pg Prt IV Chklist of Rquir Shuls (ontinu) Humn Soity of rth Myrtl - Di th orgniztion oprt on or mor hospitl filitis? If, omplt Shul H If to lin, i th orgniztion tth opy of its uit finnil sttmnts to this rturn?... Di th orgniztion rport mor thn $, of grnts or othr ssistn to ny omsti orgniztion or omsti govrnmnt on Prt I, olumn (A), lin? If, omplt Shul I, Prts I n II Di th orgniztion rport mor thn $, of grnts or othr ssistn to or for omsti iniviuls on Prt I, olumn (A), lin? If, omplt Shul I, Prts I n III Di th orgniztion nswr to Prt VII, Stion A, lin,, or out ompnstion of th orgniztion's urrnt n formr offirs, irtors, trusts, ky mploys, n highst ompnst mploys? If "," omplt Shul J Di th orgniztion hv tx-xmpt on issu with n outstning prinipl mount of mor thn $, s of th lst y of th yr, tht ws issu ftr Dmr,? If, nswr lins through n omplt Shul K. If, go to lin Di th orgniztion invst ny pros of tx-xmpt ons yon tmporry prio xption?..... Di th orgniztion mintin n srow ount othr thn rfuning srow t ny tim uring th yr to fs ny tx-xmpt ons?. Di th orgniztion t s n on hlf of issur for ons outstning t ny tim uring th yr?.... Stion ()(), ()(), n ()() orgniztions. Di th orgniztion ngg in n xss nfit trnstion with isqulifi prson uring th yr? If, omplt Shul L, Prt I Is th orgniztion wr tht it ngg in n xss nfit trnstion with isqulifi prson in prior yr, n tht th trnstion hs not n rport on ny of th orgniztion's prior Forms or -EZ? If "," omplt Shul L, Prt I Di th orgniztion rport ny mount on Prt, lin,, or for rivls from or pyls to ny urrnt or formr offirs, irtors, trusts, ky mploys, highst ompnst mploys, or isqulifi prsons? If "," omplt Shul L, Prt II Di th orgniztion provi grnt or othr ssistn to n offir, irtor, trust, ky mploy, sustntil ontriutor or mploy throf, grnt sltion ommitt mmr, or to % ontroll ntity or fmily mmr of ny of ths prsons? If, omplt Shul L, Prt III Ws th orgniztion prty to usinss trnstion with on of th following prtis (s Shul L, Prt IV instrutions for pplil filing thrshols, onitions, n xptions): A urrnt or formr offir, irtor, trust, or ky mploy? If "," omplt Shul L, Prt IV..... A fmily mmr of urrnt or formr offir, irtor, trust, or ky mploy? If "," omplt Shul L, Prt IV An ntity of whih urrnt or formr offir, irtor, trust, or ky mploy (or fmily mmr throf) ws n offir, irtor, trust, or irt or inirt ownr? If, omplt Shul L, Prt IV Di th orgniztion riv mor thn $, in non-sh ontriutions? If, omplt Shul M Di th orgniztion riv ontriutions of rt, historil trsurs, or othr similr ssts, or qulifi onsrvtion ontriutions? If, omplt Shul M Di th orgniztion liquit, trmint, or issolv n s oprtions? If, omplt Shul N, Prt I Di th orgniztion sll, xhng, ispos of, or trnsfr mor thn % of its nt ssts? If "," omplt Shul N, Prt II Di th orgniztion own % of n ntity isrgr s sprt from th orgniztion unr Rgultions stions.- n.-? If, omplt Shul R, Prt I.... Ws th orgniztion rlt to ny tx-xmpt or txl ntity? If, omplt Shul R, Prt II, III, or IV, n Prt V, lin.... Di th orgniztion hv ontroll ntity within th mning of stion ()()?. If "" to lin, i th orgniztion riv ny pymnt from or ngg in ny trnstion with ontroll ntity within th mning of stion ()()? If, omplt Shul R, Prt V, lin.. Stion ()() orgniztions. Di th orgniztion mk ny trnsfrs to n xmpt non-hritl rlt orgniztion? If, omplt Shul R, Prt V, lin Di th orgniztion onut mor thn % of its tivitis through n ntity tht is not rlt orgniztion n tht is trt s prtnrship for frl inom tx purposs? If, omplt Shul R, Prt VI Di th orgniztion omplt Shul O n provi xplntions in Shul O for Prt VI, lins n? t. All Form filrs r rquir to omplt Shul O.

5 // : PM Pg Prt V Sttmnts Rgring Othr IRS Filings n Tx Complin Chk if Shul O ontins rspons or not to ny lin in this Prt V f g h Entr th numr rport in Box of Form. Entr -- if not pplil Entr th numr of Forms W-G inlu in lin. Entr -- if not pplil Di th orgniztion omply with kup withholing ruls for rportl pymnts to vnors n rportl gming (gmling) winnings to priz winnrs? Entr th numr of mploys rport on Form W-, Trnsmittl of Wg n Tx Sttmnts, fil for th lnr yr ning with or within th yr ovr y this rturn If t lst on is rport on lin, i th orgniztion fil ll rquir frl mploymnt tx rturns? t. If th sum of lins n is grtr thn, you my rquir to -fil (s instrutions) Di th orgniztion hv unrlt usinss gross inom of $, or mor uring th yr? If, hs it fil Form -T for this yr? If to lin, provi n xplntion in Shul O... At ny tim uring th lnr yr, i th orgniztion hv n intrst in, or signtur or othr uthority ovr, finnil ount in forign ountry (suh s nk ount, suritis ount, or othr finnil ount)? If, ntr th nm of th forign ountry: u.... S instrutions for filing rquirmnts for FinCEN Form, Rport of Forign Bnk n Finnil Aounts Ws th orgniztion prty to prohiit tx shltr trnstion t ny tim uring th tx yr? Di ny txl prty notify th orgniztion tht it ws or is prty to prohiit tx shltr trnstion? If to lin or, i th orgniztion fil Form -T? Dos th orgniztion hv nnul gross ripts tht r normlly grtr thn $,, n i th orgniztion soliit ny ontriutions tht wr not tx util s hritl ontriutions? If, i th orgniztion inlu with vry soliittion n xprss sttmnt tht suh ontriutions or gifts wr not tx util? Orgniztions tht my riv util ontriutions unr stion (). Di th orgniztion riv pymnt in xss of $ m prtly s ontriution n prtly for goos If, i th orgniztion notify th onor of th vlu of th goos or srvis provi? Di th orgniztion sll, xhng, or othrwis ispos of tngil prsonl proprty for whih it ws rquir to fil Form? If, init th numr of Forms fil uring th yr Di th orgniztion riv ny funs, irtly or inirtly, to py prmiums on prsonl nfit ontrt? Di th orgniztion, uring th yr, py prmiums, irtly or inirtly, on prsonl nfit ontrt? If th orgniztion riv ontriution of qulifi intlltul proprty, i th orgniztion fil Form s rquir? If th orgniztion riv ontriution of rs, ots, irplns, or othr vhils, i th orgniztion fil Form -C? Sponsoring orgniztions mintining onor vis funs. Di onor vis fun mintin y th sponsoring orgniztion hv xss usinss holings t ny tim uring th yr?... Sponsoring orgniztions mintining onor vis funs. Di th sponsoring orgniztion mk ny txl istriutions unr stion?.... Di th sponsoring orgniztion mk istriution to onor, onor visor, or rlt prson? Stion ()() orgniztions. Entr: Initition fs n pitl ontriutions inlu on Prt VIII, lin Gross ripts, inlu on Form, Prt VIII, lin, for puli us of lu filitis Stion ()() orgniztions. Entr: Gross inom from mmrs or shrholrs. Gross inom from othr sours (Do not nt mounts u or pi to othr sours ginst mounts u or riv from thm.).. Stion ()() non-xmpt hritl trusts. Is th orgniztion filing Form in liu of Form? If, ntr th mount of tx-xmpt intrst riv or ru uring th yr Stion ()() qulifi nonprofit hlth insurn issurs. (FBAR). Humn Soity of rth Myrtl - n srvis provi to th pyor? Is th orgniztion lins to issu qulifi hlth plns in mor thn on stt?..... t. S th instrutions for itionl informtion th orgniztion must rport on Shul O. Entr th mount of rsrvs th orgniztion is rquir to mintin y th stts in whih th orgniztion is lins to issu qulifi hlth plns Entr th mount of rsrvs on hn Di th orgniztion riv ny pymnts for inoor tnning srvis uring th tx yr? If "," hs it fil Form to rport ths pymnts? If "," provi n xplntion in Shul O. f g h

6 // : PM Pg Prt VI Govrnn, Mngmnt, n Dislosur For h "" rspons to lins through low, n for "" rspons to lin,, or low, sri th irumstns, prosss, or hngs in Shul O. S instrutions. Chk if Shul O ontins rspons or not to ny lin in this Prt VI Stion A. Govrning Boy n Mngmnt orgniztion s xmpt sttus with rspt to suh rrngmnts? Stion C. Dislosur List th stts with whih opy of this Form is rquir to fil u n Stion rquirs n orgniztion to mk its Forms (or if pplil),, n -T (Stion ()()s only) Entr th numr of voting mmrs of th govrning oy t th n of th tx yr. If thr r mtril iffrns in voting rights mong mmrs of th govrning oy, or Entr th numr of voting mmrs inlu in lin, ov, who r inpnnt Di ny offir, irtor, trust, or ky mploy hv fmily rltionship or usinss rltionship with ny othr offir, irtor, trust, or ky mploy?. Di th orgniztion lgt ontrol ovr mngmnt utis ustomrily prform y or unr th irt suprvision of offirs, irtors, or trusts, or ky mploys to mngmnt ompny or othr prson? Di th orgniztion mk ny signifint hngs to its govrning oumnts sin th prior Form ws fil? Di th orgniztion om wr uring th yr of signifint ivrsion of th orgniztion s ssts? Di th orgniztion hv mmrs or stokholrs? Di th orgniztion hv mmrs, stokholrs, or othr prsons who h th powr to lt or ppoint on or mor mmrs of th govrning oy? Ar ny govrnn isions of th orgniztion rsrv to (or sujt to pprovl y) mmrs, stokholrs, or prsons othr thn th govrning oy? Di th orgniztion ontmpornously oumnt th mtings hl or writtn tions unrtkn uring th yr y th following: Th govrning oy? Eh ommitt with uthority to t on hlf of th govrning oy? Is thr ny offir, irtor, trust, or ky mploy list in Prt VII, Stion A, who nnot rh t th orgniztion s miling rss? If, provi th nms n rsss in Shul O Stion B. Poliis (This Stion B rqusts informtion out poliis not rquir y th Intrnl Rvnu Co.) Di th orgniztion hv lol hptrs, rnhs, or ffilits? If, i th orgniztion hv writtn poliis n prours govrning th tivitis of suh hptrs, ffilits, n rnhs to nsur thir oprtions r onsistnt with th orgniztion's xmpt purposs? Hs th orgniztion provi omplt opy of this Form to ll mmrs of its govrning oy for filing th form? Dsri in Shul O th pross, if ny, us y th orgniztion to rviw this Form. if th govrning oy lgt ro uthority to n xutiv ommitt or similr ommitt, xplin in Shul O. Di th orgniztion hv writtn onflit of intrst poliy? If, go to lin Wr offirs, irtors, or trusts, n ky mploys rquir to islos nnully intrsts tht oul giv ris to onflits?.... Di th orgniztion rgulrly n onsistntly monitor n nfor omplin with th poliy? If, sri in Shul O how this ws on Di th orgniztion hv writtn whistllowr poliy? Di th orgniztion hv writtn oumnt rtntion n strution poliy? Di th pross for trmining ompnstion of th following prsons inlu rviw n pprovl y inpnnt prsons, omprility t, n ontmpornous sustntition of th lirtion n ision? Th orgniztion s CEO, Exutiv Dirtor, or top mngmnt offiil Othr offirs or ky mploys of th orgniztion.. If to lin or, sri th pross in Shul O (s instrutions). Di th orgniztion invst in, ontriut ssts to, or prtiipt in joint vntur or similr rrngmnt with txl ntity uring th yr? If, i th orgniztion follow writtn poliy or prour rquiring th orgniztion to vlut its prtiiption in joint vntur rrngmnts unr pplil frl tx lw, n tk stps to sfgur th vill for puli insption. Init how you m ths vill. Chk ll tht pply. Own wsit Anothr's wsit Upon rqust Dsri in Shul O whthr (n if so, how) th orgniztion m its govrning oumnts, onflit of intrst poliy, n finnil sttmnts vill to th puli uring th tx yr. Stt th nm, rss, n tlphon numr of th prson who posssss th orgniztion's ooks n rors: u Brittny Johnson Humn Soity of rth Myrtl - Othr (xplin in Shul O) Pintuky Driv Glivnts Frry SC --

7 // : PM Pg Prt VII Compnstion of Offirs, Dirtors, Trusts, Ky Employs, Highst Compnst Employs, n Inpnnt Contrtors Chk if Shul O ontins rspons or not to ny lin in this Prt VII Stion A. Offirs, Dirtors, Trusts, Ky Employs, n Highst Compnst Employs Complt this tl for ll prsons rquir to list. Rport ompnstion for th lnr yr ning with or within th orgniztion's tx yr. List ll of th orgniztion's urrnt offirs, irtors, trusts (whthr iniviuls or orgniztions), rgrlss of mount of ompnstion. Entr -- in olumns (D), (E), n (F) if no ompnstion ws pi. List ll of th orgniztion's urrnt ky mploys, if ny. S instrutions for finition of "ky mploy." List th orgniztion's fiv urrnt highst ompnst mploys (othr thn n offir, irtor, trust, or ky mploy) who riv rportl ompnstion (Box of Form W- n/or Box of Form -MISC) of mor thn $, from th orgniztion n ny rlt orgniztions. List ll of th orgniztion's formr offirs, ky mploys, n highst ompnst mploys who riv mor thn $, of rportl ompnstion from th orgniztion n ny rlt orgniztions. List ll of th orgniztion s formr irtors or trusts tht riv, in th pity s formr irtor or trust of th orgniztion, mor thn $, of rportl ompnstion from th orgniztion n ny rlt orgniztions. List prsons in th following orr: iniviul trusts or irtors; institutionl trusts; offirs; ky mploys; highst ompnst mploys; n formr suh prsons. () () () () () Chk this ox if nithr th orgniztion nor ny rlt orgniztion ompnst ny urrnt offir, irtor, or trust. (A) (B) (C) (D) (E) (F) Nm n Titl VICKI BLAIR Avrg hours pr wk (list ny hours for rlt orgniztions low ott lin) BOD PRESIDENT Humn Soity of rth Myrtl - Brittny Johnson BOD Trsurr KATHERINE KEATON BOD VICE-PRESIDENT Juy Blnk BOD Srtry Position (o not hk mor thn on ox, unlss prson is oth n offir n irtor/trust) Iniviul trust or irtor Institutionl trust Offir Ky mploy Highst ompnst mploy Formr Rportl ompnstion from th orgniztion (W-/-MISC) Rportl ompnstion from rlt orgniztions (W-/-MISC) Estimt mount of othr ompnstion from th orgniztion n rlt orgniztions () () () () () ()

8 // : PM Pg Prt VII Stion A. Offirs, Dirtors, Trusts, Ky Employs, n Highst Compnst Employs (ontinu) (A) Nm n titl Humn Soity of rth Myrtl - (B) Avrg hours pr wk (list ny hours for rlt orgniztions low ott lin) Iniviul trust or irtor Institutionl trust Offir (C) Position (o not hk mor thn on ox, unlss prson is oth n offir n irtor/trust) Ky mploy Highst ompnst mploy Formr (D) Rportl ompnstion from th orgniztion (W-/-MISC) (E) Rportl ompnstion from rlt orgniztions (W-/-MISC) (F) Estimt mount of othr ompnstion from th orgniztion n rlt orgniztions Su-totl.... u Totl from ontinution shts to Prt VII, Stion A u Totl ( lins n ) u Totl numr of iniviuls (inluing ut not limit to thos list ov) who riv mor thn $, of rportl ompnstion from th orgniztion u Di th orgniztion list ny formr offir, irtor, or trust, ky mploy, or highst ompnst mploy on lin? If, omplt Shul J for suh iniviul For ny iniviul list on lin, is th sum of rportl ompnstion n othr ompnstion from th orgniztion n rlt orgniztions grtr thn $,? If, omplt Shul J for suh iniviul Di ny prson list on lin riv or ru ompnstion from ny unrlt orgniztion or iniviul for srvis rnr to th orgniztion? If, omplt Shul J for suh prson Stion B. Inpnnt Contrtors Complt this tl for your fiv highst ompnst inpnnt ontrtors tht riv mor thn $, of ompnstion from th orgniztion. Rport ompnstion for th lnr yr ning with or within th orgniztion's tx yr. (A) (B) Nm n usinss rss Dsription of srvis (C) Compnstion Totl numr of inpnnt ontrtors (inluing ut not limit to thos list ov) who riv mor thn $, of ompnstion from th orgniztion u

9 // : PM Pg Prt VIII Sttmnt of Rvnu Chk if Shul O ontins rspons or not to ny lin in this Prt VIII Contriutions, Gifts, Grnts n Othr Similr Amounts Progrm Srvi Rvnu Othr Rvnu f g h f g Frt mpigns Mmrship us Funrising vnts Rlt orgniztions Govrnmnt grnts (ontriutions)... All othr ontriutions, gifts, grnts, n similr mounts not inlu ov nsh ontriutions inlu in lins -f: Totl. A lins f..... All othr progrm srvi rvnu f $ Totl. A lins f..... Invstmnt inom (inluing ivins, intrst, n othr similr mounts) u Inom from invstmnt of tx-xmpt on prosu Royltis u Gross rnts Lss: rntl xps. Rntl in. or (loss) (i) Rl (ii) Prsonl Nt rntl inom or (loss) Gross mount from (i) Suritis (ii) Othr sls of ssts othr thn invntory Lss: ost or othr sis & sls xps. u Busn. Co Gin or (loss) Nt gin or (loss) u Gross inom from funrising vnts (not inluing $ of ontriutions rport on lin ). S Prt IV, lin , Lss: irt xpnss, Nt inom or (loss) from funrising vnts u Gross inom from gming tivitis. S Prt IV, lin Lss: irt xpnss Nt inom or (loss) from gming tivitis u Humn Soity of rth Myrtl - Gross sls of invntory, lss rturns n llowns Lss: ost of goos sol Nt inom or (loss) from sls of invntory Misllnous Rvnu All othr rvnu., Totl. A lins. Totl rvnu. S instrutions , u u Busn. Co u u (A) (B) (C) (D) Totl rvnu Rlt or Unrlt Rvnu xmpt funtion rvnu usinss rvnu xlu from tx unr stions -, ADOPTION FEES,, PREVENTATIVE HEALTH INCOME,, Mmrship us,, MICROCHIP PROGRAM,, PUBLIC ASSISTANCE,,,, u,,,,

10 // : PM Pg Prt I Sttmnt of Funtionl Expnss Stion ()() n ()() orgniztions must omplt ll olumns. All othr orgniztions must omplt olumn (A). Chk if Shul O ontins rspons or not to ny lin in this Prt I Do not inlu mounts rport on lins,,,, n of Prt VIII. Humn Soity of rth Myrtl - Grnts n othr ssistn to omsti orgniztions (A) (B) (C) (D) Totl xpnss Progrm srvi Mngmnt n Funrising xpnss gnrl xpnss xpnss n omsti govrnmnts. S Prt IV, lin Grnts n othr ssistn to omsti iniviuls. S Prt IV, lin Grnts n othr ssistn to forign orgniztions, forign govrnmnts, n forign iniviuls. S Prt IV, lins n Bnfits pi to or for mmrs Compnstion of urrnt offirs, irtors, f g trusts, n ky mploys Compnstion not inlu ov, to isqulifi prsons (s fin unr stion (f)()) n prsons sri in stion ()()(B) Othr slris n wgs Pnsion pln ruls n ontriutions (inlu stion (k) n () mployr ontriutions) Othr mploy nfits Pyroll txs Fs for srvis (non-mploys): Mngmnt..... Lgl Aounting Loying Profssionl funrising srvis. S Prt IV, lin Invstmnt mngmnt fs Othr. (If lin g mount xs % of lin, olumn,,,,,,,,, (A) mount, list lin g xpnss on Shul O.) Avrtising n promotion Offi xpnss.. Informtion thnology Royltis Oupny Trvl Pymnts of trvl or ntrtinmnt xpnss for ny frl, stt, or lol puli offiils Confrns, onvntions, n mtings... Intrst Pymnts to ffilits Dprition, pltion, n mortiztion... Insurn Othr xpnss. Itmiz xpnss not ovr ov (List misllnous xpnss in lin. If lin mount xs % of lin, olumn (A) mount, list lin xpnss on Shul O.).... All othr xpnss Totl funtionl xpnss. A lins through..... Joint osts. Complt this lin only if th orgniztion rport in olumn (B) joint osts from omin utionl mpign n funrising soliittion. Chk hr u if following SOP - (ASC -) ,, VET CARE,,, SPAY/ NEUTER SURGERIES,,, Supplis,,, PREVENTATIVE HEALTH,,,,,,,,,,,

11 // : PM Pg Prt Bln Sht Chk if Shul O ontins rspons or not to ny lin in this Prt (A) (B) Bginning of yr En of yr Assts Liilitis Nt Assts or Fun Blns othr sis. Complt Prt VI of Shul D Lss: umult prition ,,, Invstmnts pulily tr suritis... Invstmnts othr suritis. S Prt IV, lin Invstmnts progrm-rlt. S Prt IV, lin Intngil ssts Othr ssts. S Prt IV, lin Totl ssts. A lins through (must qul lin )...,, Aounts pyl n ru xpnss. Grnts pyl Dfrr rvnu Tx-xmpt on liilitis Esrow or ustoil ount liility. Complt Prt IV of Shul D Lons n othr pyls to urrnt n formr offirs, irtors, Humn Soity of rth Myrtl - Csh non-intrst ring Svings n tmporry sh invstmnts. Plgs n grnts rivl, nt Aounts rivl, nt Lons n othr rivls from urrnt n formr offirs, irtors, trusts, ky mploys, n highst ompnst mploys. Complt Prt II of Shul L... Lons n othr rivls from othr isqulifi prsons (s fin unr stion (f)()), prsons sri in stion ()()(B), n ontriuting mployrs n sponsoring orgniztions of stion ()() voluntry mploys' nfiiry orgniztions (s instrutions). Complt Prt II of Shul L ts n lons rivl, nt... Invntoris for sl or us Prpi xpnss n frr hrgs... Ln, uilings, n quipmnt: ost or trusts, ky mploys, highst ompnst mploys, n isqulifi prsons. Complt Prt II of Shul L Sur mortggs n nots pyl to unrlt thir prtis Unsur nots n lons pyl to unrlt thir prtis Othr liilitis (inluing frl inom tx, pyls to rlt thir prtis, n othr liilitis not inlu on lins -). Complt Prt Totl liilitis. A lins through.. Orgniztions tht follow SFAS (ASC ), hk hr u n omplt lins through, n lins n. Unrstrit nt ssts Tmporrily rstrit nt ssts. Prmnntly rstrit nt ssts Orgniztions tht o not follow SFAS (ASC ), hk hr u n omplt lins through., of Shul D Cpitl stok or trust prinipl, or urrnt funs Pi-in or pitl surplus, or ln, uiling, or quipmnt fun Rtin rnings, nowmnt, umult inom, or othr funs Totl nt ssts or fun lns. Totl liilitis n nt ssts/fun lns ,,,,,,,,,,

12 // : PM Pg Prt I Ronilition of Nt Assts Chk if Shul O ontins rspons or not to ny lin in this Prt I Totl rvnu (must qul Prt VIII, olumn (A), lin ) Totl xpnss (must qul Prt I, olumn (A), lin ) Rvnu lss xpnss. Sutrt lin from lin Nt ssts or fun lns t ginning of yr (must qul Prt, lin, olumn (A)).. Nt unrliz gins (losss) on invstmnts Dont srvis n us of filitis.. Invstmnt xpnss Prior prio justmnts Othr hngs in nt ssts or fun lns (xplin in Shul O).... Nt ssts or fun lns t n of yr. Comin lins through (must qul Prt, lin, olumn (B)) Prt II Finnil Sttmnts n Rporting Chk if Shul O ontins rspons or not to ny lin in this Prt II Aounting mtho us to prpr th Form : Csh Arul Wr th orgniztion's finnil sttmnts ompil or rviw y n inpnnt ountnt? If "," hk ox low to init whthr th finnil sttmnts for th yr wr ompil or Wr th orgniztion's finnil sttmnts uit y n inpnnt ountnt?... If "," hk ox low to init whthr th finnil sttmnts for th yr wr uit on of th uit, rviw, or ompiltion of its finnil sttmnts n sltion of n inpnnt ountnt? If th orgniztion hng ithr its ovrsight pross or sltion pross uring th tx yr, xplin in th Singl Auit At n OMB Cirulr A-? If, i th orgniztion unrgo th rquir uit or uits? If th orgniztion i not unrgo th Othr If th orgniztion hng its mtho of ounting from prior yr or hk Othr, xplin in Shul O. rviw on sprt sis, onsolit sis, or oth: Sprt sis Consolit sis Both onsolit n sprt sis Sprt sis If to lin or, os th orgniztion hv ommitt tht ssums rsponsiility for ovrsight Shul O. Humn Soity of rth Myrtl - sprt sis, onsolit sis, or oth: Consolit sis As rsult of frl wr, ws th orgniztion rquir to unrgo n uit or uits s st forth in rquir uit or uits, xplin why in Shul O n sri ny stps tkn to unrgo suh uits. Both onsolit n sprt sis,,,,,