NON PROFIT INCOME TAX
NON PROFIT BACKGROUND INFORMATION
Name of organization
Doing business as
Employer identification number (EIN)
Year of formation
State of legal domicile
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website
Group exemption number
OFFICER INFORMATION
Name of principal officer
Address of principal officer
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ACTIVITIES AND GOVERNANCE
Briefly describe the organization's mission or most significant activities
Number of voting members of the governing body
Number of independent voting members of the governing body
Total number of individuals employed in calendar year
Total number of volunteers estimate if necessary
Total unrelated business revenue
REVENUE
Contributions and grants
Program service revenue
Investment income
Other revenue
EXPENSES
Grants and similar amounts paid
Benefits paid to or for members
Salaries other compensation employee benefits
Professional fundraising fees
Other expenses
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Signature of officer
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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