Form
Request For 45R Credit Only
Exempt Organization Business lncome Tax Return
990-T
For calendar year 2011 or other tax year begi nnin g
6/30
and ending
Department of the T reasury
lnternal Revenue Service
(U
Print
or
Type
~empt under section
B
=
408(e)
_ 408A
529(a)
e
8
e )( 3 )
X 501 (
1
7/01
201 2
1
2011
2011,
ogen lo Public lnspection lor
5 1(cX3J Organization s Only
.. See separate instruc tions.
UCheck
box if
address chanaed
A
OMB No. 1545·0687
(and proxy tax under section 6033(e))
220(e)
530(a)
~k
value o f ait asse ts at
of year
1,019, 721 .
Check box of name changed and see ons1rucllons.)
D Em ploycr identification n umbcr
(Em ployees' trust,
see onstructoons.)
AS SOCIATED STUDENTS, CSU, FRESNO
2771 EAST SHAW AVENUE
FRESNO, CA 93710
F Group exemption number (See instruetions.} .
94 - 2371885
E
Unrelated business ac tivity
codes (See instructions.)
....
. . r 1501 (e) eorporation r l 50 1(e) trust
G Cheek orga niza tion type. ...
I
r l 401 (a) trus! J l Other trus!
Dese ribe the organization's primary unrelated business aetivity .
H
...
During the tax year, was the eorporation a subsidiary in an affiliated group or a parent-subsidiary eontrolled group? . .. .... 0Yes
0
No
lf 'Yes,' enter the name and identifying number of the parent eorporation... ....
J
The books are in eare of
1Pai1 1
I Unrelated
....
KATE TUCKNESS
Trade or Business lncome
Telephone number ....
559-278-0800
(B) Expenses
(C) Net
(A) lncome
:t;,)
1 a Gross reeeipts or sales . ..
b Less returns and allowances . .. .
e Balanee
....
}'''
'iL ~~;_,~-c'_l:b.:
2
Cost of goods sold (Sehedule A, line 7).... ... . . . . . ...... . .. .
2
3
Gross profit. Subtraet line 2 from lin e 1e.....................
3
<t~l.!J:i~ :tt ·,l ,.,.;t~~,.
';rf;.' . ~~~
1e
ff
4a Capital gain net ineome (attaeh Sehedule D) . . . .... . ..... . .. .
4a
i{§r!' '1 ':l' ~!~:. !. -~ -§.':!!~
b Net gain (loss) (Form 4797, Part 11, li ne 17) (attach Form 4797) ... ... ... .. .
4b
. ~.;.',:.[3~i'~~-;;:
e Capital loss deduetion lor lrusts. .. ....... ... . .. ......... . . ..
5 lneome (loss) from partnerships and S eorporations
(attaeh statement} .................. . ..... .. .......... . . . ..
4e
Rent ineome (Sehedule C) .. .... . . . . . . . . . ' . . .. .. . . .. ..
6
7
8
Unrela ted debt-finaneed ineom e (Sehedule E)........ .. .. ....
lnterest, annuilies, royalties, and rents tram eontrolled
organizntions (Sehedule F) ..... . . . ............. . ...........
7
9
lnvestment íncome of a sectíon 501 (c)(7), (9), or (17) organization (Sch G) . . .
..
'·
.:::t:
;~t···~{/:f·o~
5
6
.\:
~~-,,,..
8
9
Exp loi ted exempt aetiv ity income (Sehedule I) ... . . . . . .
10
11
Adve rtising ineome (Sehedule J) ..... .... ........ . . . . . . . . .. .
11
12
Other ineome (See instruetions; attaeh sehedule.)
10
C..''l'.?t~:.:
i,C.~~Th}~;-T ,-;JJl&J:.,
;~.:
12
/~:~è!
·r.'
.'!,;
-Total.
-------- ---- - ------ - ----- - Combine lines 3 thro ugh 12.. ... .. . .. . . . .. ..... ..... .. 13
o
IPart lf J Deductions Not "faken Elsewher.e (See instructions for limitations on deductions.)
13
o
o.
O.
(Except for contnbuttons, deducttons must be dtrectly connected wtth the unrelated bustness 1ncome.)
14
Compensation of offieers, direetors, and trustees (Sehedule K).
15
Salaries and w ages . . . . . . . . . . . . . . . . . . . . . .
14
16
Repairs and m ain tenance... ....... .... ..... ....• ..... ... .. . . . .......... .
17
Bad debts . ..... ....... ...... . . . .... . . . ....... .... ... . .. . . .. . ..... ... . .. . . . .. ... ... ... ..... . .... ..... . .
17
18
lnterest (attach sehedule).... .. . .. . . ......... .. ......... . .. .. .
18
. . .. .
19 Taxes and lieenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o •••• •••• •
• ••• • •
• •••
o ••• ••••••• •••••• •••• •• •••• •
• ••
. .......... . ..... .. . ... .. .. ......... .
20
Charitable eontributions (See instruetions lor limitation rules.)......... ... ... ... .... . .... . . .. . .......... .. .
21
Depreeiation (attaeh Form 4562) ..... ... .. ... ........ . . .... ......... . ........ li-=
21.:..._lt--
-
-
15
16
19
20
- - ----1
22b
22 Less depree ia tion cla im ed on Sehedule A and elsewhere on return ..... . . . . . . . . IL. C. :.22:: . . :c.aL..,_I_ __ _ _ __ t-=-=.;;.t-23 Dep le tion . .... .... ..... ...... . .. .... . ... ... . .... . .......... . .. . . .... . . .. ... ....... . .. .... ...... ..... . . . 23
24 Contributions lo deferred eompensation plans..... . .. .. .
24
25
Emp loyee benefit programs. . . . . . . . . . . . . . . . .
. . . ... .. . .
26
27
28
29
30
31
32
33
. . . . . . . .. .
....... .. ..
. . . ... ... .
Exeess exempt expenses (Sehedule 1).
Excess readership eosts (Sehedule J) ....... . .. . . . .. . . . .... . .. ... ....... ... ..... . . . . ....... .. ......... .
Other deduetions (attaeh sehedule) ......... .. . ..... .... .. . . .................................. . .. .
Total deducti ons. Add lines 14 through 28 ...
. . . . . . . . . . . . . . . . . .... ..... .. ... .
Unre la ted business taxable ineome before net operating loss deduetion. Subtraet line 29 from line 13 .
Net operating loss deduction (limi ted lo the amounl on line 30) . . . . . .
. .. .. .. . . ... . . .... .... .
Unrelated business taxable ineome before speei fie deduetion. Subtrael line 31 from line 30 ........... .... .
Speei fie deduction (Generally $1 ,000, but see Ime 33 instructions lor exceptions.). . .
. . ....... . .
26
27
28
29
30
31
32
33
34
Unrelated bu sine ss taxable in c ome. Subtract line 33 from line 32. l f line 33 is greater than line 32, enter
the smaller of ze ro or line 32 . .
.. ... .... ..
.. ....... .. .. ..
. ... .. . ... .
34
BAA Far Paperwork Reducti on Ae t Noti ce 1 se e in stru etions.
------
25
TEEA0205L 12/1211 1
O.
Form 990-T (2011 )
'Form 990-T (2011)
94-2371885
ASSOCIATED STUDENTS , CSU, FRESNO
Page 2
IPart 111 ITax Computation
35 Organization s Taxable as Corporation s. See instructions for tax computation.
Controlled group members (sections 1561 and 1563) check here ...
See instruction s and:
a Enter your share of the $50,000, $25,000, and $9,925,000 taxable income brackets (in that order):
O.
I
I
~·.
I
;)
~ . ·',
<1> 1$
<2>1$
<3> 1$
b Enter organ ization's share of: (1) Additional 5% tax (not more than $1 1,750) .... . I$
:
(2) Additional 3% tax (not more than $100,000) . . . . . . . . . .. . . . . . . . . . . . . . ... . . ... . . I$
35c
e lncome tax on the amount on line 34 ............ ..... . . .. ..... ' ... .... ' ' ' . . . ,, ...... ' . . . . . . ' . .. .... .
36 Trusts Taxable at Trust Rates. See instructions for tax computation. lncome tax on the amount
36
on line 34 from:
Tax rate schedule or
Schedule D (Form 1041). .. ... . . . . .. .. . . .. . .... ... . ..
37 Proxy tax. See instructions . . .......... . . . ... . . . . . .. . . . . . . . . .. . . . . . . . ..
.. . . . .. .. .. . .... .. .. ........
37
38 Alternative minimum tax .... ... ... .... .... ... .. ..... . ...... .. ...... .. ... .... ... .. ....... . .. . .... . ... . . .. 38
39 Total. Add lines 37 and 38 lo line 35c or 36, whichever applies.... ... . .. . . . ' ' ...... ' ..... ..... ' . ' ... .. ... ' 39
l•f?arti iV 'I Tax and Payments
40 a Fore ign tax credit (corporations attach Form 11 18; trusts attach Form 1116).
40a
,,
b Other credits (see instructions).. . .. . .. ... .. .. . . . . . . . . . . . . . . . . . . . ' . . . ' . . . . ... . 40b
e General business credit. Attach Form 3800 (see instructions) . . .. .. .... . . . ..... 40c
~._
d Credit for prior year minimum tax (attach Form 8801 or 8827) .... .. .. . . ... .... 40d
e Total c redits. Add lines 40a through 40d ... ................................................. . ............ 40e
41 Subtract line 40e from line 39 . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' ' .. . . . . . . . . . ' . .... . .... . .... ..... 41
42 Other taxes. Check if from:
Form 4255 0Form 8611 .. 0Form 8697
0Form 8866
Other (attach schedule) .. ... ... ........... . ...... . ................. . .......... .... ........... . .. .... 42
43 Total tax. Add lines 41 and 42 ....... ... .. . . . . . . . . . . .. .... . . . . .... .. . . . . . .. . . . . .. . .. . . ......... . ...... 43
44 a Pay ments: A 2010 overpayment credited to 2011 ... . ...... . ..... . . ..... . . . .. 44a
b 2011 estimated tax payments .. .... . . .. . . . . .. . . . . . .. ........ .. . . . . . . . . . . . . . . . 44b
-l
'q
e Tax deposited with Form 8868 ... ..... ..... . .... ...... . ......... .... .... . .... 44 c
d Foreign organizations: Tax paid or withheld at source (see instructions} ... . .... 44d
~~: r,:
e Backup withholding (see instructions). ......... . .. . .... .... . . ......... . ....... 44e
f Credit for small employer health insurance premiums (Attach Form 8941). . .. ... 44f
989 .
g Other credits and payments:
B Form 2439
~ ~·!
Other
Total. ...
44g
Form 4136
. . . . . . . ...... .. . . . ' .
45
45 Total payments. Add linP.s 44a through 44g .. . . . . . .. . . . . . . . . . . ' ... . . . . . ' .
.
O
...
...
...
O
'
''
o.
'''
o.
o.
O
O
o.
''
..
;
...
O
.. o
46 Estimated tax penalty (see instructions). Check if Form 2220 is attached . . . ............ ... ...
''
989.
''
...
46
47 Tax du e. l f line 45 is less than the total of lines 43 and 46, enter amount owed ... . ... ... .. . . . . . .
47
48 Overpaymen t. lf line 45 is larger than the total of lines 43 and 46, enter amount overpaid .. . .... .... ..... .,. 48
Refunded .,. 49
49 Enter the amount of line 48 you want: Credited t o 2012 estimated tax .,.
'
''
'
989.
989 .
I
I Part V">l Statem ents Re_gardinq Certai n Activities and Other lnformation (see instructions)
1 At any time duri ng the 2011 calendar year, did the organization have an interest in or a signature or other authority over a
financial account (bank, securities, or other) in a foreign country? lf YES, the organization may have to file Form TD F 90·22.1,
Report of Foreign Bank and Financial Accounts. lf YES, enter the name of the foreign country here .....
...
Yes
------------
2 During the tax year, did the organization receive a distribution from, or was it the grantor of, or transferor to, a foreign trus!?.
lf YES, see instructions for other forms the organization may have lo file.
1
3 Enter the amount of tax·exempt interest received or accrued during the tax year.,. $
- Cos t o f G00 d s Sold E nter met hod o f 1nventory va ualton
...
S eh eduIe A
'.
1
6 lnventory at end of year. . .... ' .
6
2 Purchases ... . . . . . .. ..... . .. ...... .....
2
3 Co~of~bo ~ ... .. . .. .. .... . ..... . . . .. .
4 a Additional section 263A costs (attach schedule)
3
7 Cast of goods sold. Subtract
line 6 from line 5. Enter here
and in Part I, line 2. ... .. ....
7
1
lnventory at beginning of year. . .
b 011-;r~o~s-
'
.
'
.
'
'
- - - - - - - - - - - - - - -
(attach sch) - - - - _ _ _ _ _ _ _ _ _ _ _
5 Total. Add lines 1 through 4b ...........
Sign
Here
Paid
Preparer
Use
Only
BAA
No
'
Yes
4a
No
8 Do the rules of section 263A (with respect to
property produced or acquired for resale) apply
to the organization? .... . .
.. .. ... ' ..
4b
5
''' .
'.'.'
'
l ~U
1
... Di&tj"o~ ll.1ie' S.
PrintfType preparer's name
t
xecutJ.Ve
J.r e -~~}he
iRSdiSCuss lh•s relurnw•lh
SU
k' .,.. en,...,
the preparer shown below (se e
... i\('ixlli ary Corp. instructions)? fxl ves Q No
I \\l
Adishian-Astorf~è
0
IPr:~éa.~ l
Date
Fa u s t Hinoj o
Fausto Hinojosa, CPA, CFE
~
Fum's name
Price, Paiqe and Companv
Flfm's add1ess .,. 677 Scott Avenue
Clovi s, CA 93612
TEEA0202L
CFE
/ "L.
/·t/; '2.....
Check
U•r
self-employed
Flfm's EIN ...
Phone no.
12112/11
I
'
U nd~~erjury, I declare that I have examined this return, includ1ng accompanying schedules and slalemenls, and lo lhe best of my knowledge and belief, it is truc.
correct and complete. Declaral ion of preparer (other than taxpayer) is ba~if~ inforrnation oE;:hich preparer.has any ~owted~r
'\.
I
I
J P TIN
P00196912
77-0203007
(559) 299-9 540
Form 990-T (2011)
·Form 990-T (2011)
ASSOCIATED STUDENTS , CSU, FRESNO
94 - 2371885
Page 3
Schedule C - R ent lncome (From Real Property and P ersonal P roperty Leased With Real Property) Csee instructions)
Description of property
(1)
(2)
(3)
(4)
2 Rent received or accrued
(a) From personal property
(if the percentage of rent lor f.ersonal
property is more than 10° o but
not more than 50%)
3(a) Deductions directly connected
with the income in columns 2(a) and 2(b)
(attach schedule)
(b) From real and personal property
(i f the percentage of rent for
~ersonal property exceeds 50% or
if t e rent is based on profit or income)
(1)
(2)
(3)
(4)
Total
Total
(b) Total deductions. Enter
here and on page 1, Part
I, li ne 6, column (8).. ... ....
(e) Total in co me. Add totals of columns 2(a) and 2(b). Enter
here and on page 1, Part I, line 6, column (A) ... .... ....... ....
Schedule
E-
Unre l ated Debt-Financed lncome (see instructions)
2 Gross income from
or allocable to
debt-financed property
1 Description of debt-financed property
3 Deductions directly connected with or al locable to
debt-financed property
(a) Straight li ne
depreciation (attach sch)
(b) Other deductions
(attach schedule)
6 Column 4
7 Gross income
divided b?
column
reportable
(column 2 x column 6)
8 Allocable deductions
(column 6 x total of
(1)
(2)
(3)
(4)
4 Amount of average
acquisition debt on or
allocable lo debt·financed
property (attach schedule)
5 Average adjusted basis of
or allocable to debt- financed
property (attach schedule)
(2)
%
%
(3)
1)
(4)
%
(1)
columns 3(a) and 3(b))
o
Enter here and on page 1, Enter here and on page 1,
Part I, line 7, column (A). Part I, line 7, column (8) .
Totals .......... .. . ...... . . . . . . . . . . . . ... ...... ...... ...... . .... . . . . ....... .. . . .... ....
Total dividends-received deducti ons included in column 8.. . .......... . .... . ..... . . ...... . .... ..... .... .......
....
Schedule F - l nterest Annuities Rovaltie s and Rent s From Control le d Orqanization sJsee instructions)
Exempt Controlled Organizations
1 Name of controlled
organization
2 Employer
identification
number
4 Total of specified
3 Net unrelated
income (loss)
(see insl ructions)
payments made
5 Part of column 4
that is included
in the controlling
organization's
gross income
6 Deductions directly
connected with income
in column 5
(1)
(2)
(3)
(4)
Nonexemp t Controlled Organ1zat1ons
7 Taxable lncome
8 Net unrelated
income (loss)
(see instructions)
1O Part of column 9 that is
9 Total of specified
payments made
included in the controlling
organization's gross income
11 Deductions directly
connected with income
in column 10
(1)
(2)
( 3)
(4)
Add columns 5 and 1O. Enter
here and on page 1, Part I, Ime
8, column (A).
To tals .. .. . . . . . ... . ... . . .. . . ..... . .. . ....... . ... . . . . . . . ' . .
. . . . ......
BAA
TEEA0203 l
12/12/11
Add columns 6 and 11. Enter
here and on page 1, Part I, line
8, co lumn (8) .
Form 990-T (2011)
CSU , FRESNO
94-2371885
Sehedule G - lnvestment lneome of a Seetion 501(e){7), (9), or (17) Organization (see instructions)
• 'Form 990-T (2011) ASSOCIATED STUDENTS,
1 Description of income
3 Deductions
direclly connecled
(allach schedule)
2 Amounl of mcome
4 Set-asides
(allach schedule)
Page 4
5 Total deduclions and
set-asides (column 3
plus column 4 )
(1)
(2)
(3)
(4)
Enter here and on page 1,
Part I, line 9, column (A) .
....
Sehedule I - Ex l01ted Exem
Totals ............ . . . ... . . . . . . . . .
.
.
'11~·"'-·
.··:"•
.:
,r~t
~··
..•
.,
Enter here and on page 1,
Part I, line 9, column (8).
..
lneome (see instruclions)
4 Net income
5 Gross income
6 Expenses
7 Excess
(loss) !rom
!rom activity
attribulab le lo
direclly connected
exempt expenses
unrelaled trade or that is not unrelated
column 5
with production of
(column 6 minus
business
unrelated business qusmess (column 2
column 5, but not
mmus
column
lf
a
income
income
more than column 4).
gam, compu e
columns 5 lhrough 7.
3 Expenses
2 Gross
unrelaled
business
income
!rom lrade
or business
1 Descriplion of exploiled activity
•'.
3/.
(2)
(3)
4
Enter here and
on page 1,
Part l, line 10,
column (A)
Enter here and
on pa9e 1,
Part I, llne 10,
column (8).
Enter here and
on page 1,
Part li, line 26.
Totals ...... ....................... ....
S ehed u Ie J
.
- Ad ve rfISing
neome (See instructions.)
IPárt JI. \Ineome From Periodieals Reported on a Consolidated Basis
2 Gross
advertising
income
1 Name of peri odical
3 Direcl
advertising
costs
4 Adverlising gain or 5 Circulalion
(loss) (column 2
income
minus column 3). lf a
gain, compute
columns 5 lhrouoh 7.
6 Readership
costs
..
(1)
7 Excess readership
costs (column 6
minus column
5, but nol
more than column 4).
• e..-,
l""·
(2)
·'·
F;
(3)
. ~r
(4)
.~-\\''i. f'~ .
Totals (carry lo Part 11 , line (5)) ..... ....
I Part 11
\ lneome From Periodieal s Reported on a Separate Basis (For each periodical listed in Part li , fi ll in columns 2 through
7 on a l1ne-by-lme bas1s.)
3 Direcl
advertising
costs
2 Gross
adverlising
income
1 Name of periodical
4 Advertising gain or
(loss) (col umn 2
minus column 3). lf a
gain, compute
columns Sthrouqh 7.
6 Readership
5 Circulalion
income
costs
7 Excess readershi p
costs (col umn 6
minus column
5, but not
more than column 4).
_(1)
(2)
(3)
(4)
(5) Totals from Part I. .. ...
•
•
•
o
•
•
•
•
Enter here and
on page 1,
Part • l1ne 11,
column (A).
Totals, Part li (lines 1-5) .. . . . . ... . .
S ehedu Ie K
-
Enler here and
on page 1,
Part • l1ne 11,
column (8) .
I;! )
'<
. 't'
•
'l
Enter here and
on page 1,
Part 11, line 27.
L
,,
....
Compensa t 1on o fOff 1ee rs, D 1ree ors, an dT ru st ees (see instructions)
1 Name
2 Title
3 Percent of
lime devoled
lo business
4 Compensation allribulable
lo unrelated business
%
%
%
%
.
Total. En ter here and on page 1, Part l i, lin e 14 .... . . . . ' . . . . . . . . . ' . . . ' . .
8AA
TEEI\0204 L 12112111
. .... . . . . . . . . . . . . . . . . . . ..
....
Forrn 990-T (2011)
Form
8941
Department of the Treasury
lnternal Revenue Service
OMB No. 1545-2198
Credit for Small Employer Health lnsurance Premiums
2011
... lnformati on about Form 8941 and its instructions is avail abl e at www.irs.gov/form894 7.
... Attach to y our tax return.
Attachment
Sequence No.
63
Name(s) shown on return
ASSOCIATED STUDENTS, CSU, FRESNO
Enter the number of individuals you employed duri ng the tax year who are conside red emp loyees lor
purposes of this cred it (see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. ... ............... 1--'1-t-- -- - - ---'1=32 Enter the number of lull-time equiva lent employees you had lor the tax year (see instructions). 11 you entered
25 or more , skip lines 3 through 11 and enter -0- on line 12. . ....... . ......... . .. .. ................ .
2
3 Average annual wages you paid for the tax year (see instructions). lf you entered $50,000 or more, skip lines
4 through 11 and enter -0- on line 12 .... . . ... .. ........ . . .. . ........... . . . .... .. .. .. . . . . .... . . ..... . . . .
3
3
43 , 936.
4 Premiums you paid during the tax year for employees included on line 1 for health insurance coverage under
..:...,+-----=2..:4.L,..::5::.:2:::..0:::..:..
.
a qualifying arrangement (see instructions) . . . . .................. . ... .. .. .. . .... . . . .... . ... .. ..... . . .... ~-,-4
5 Premiums you would have entered on lin e 4 if the total premi um for each employee eq ualed the average
premium for the small group market in which you offered health insurance cove rage (see instructions) . . . . .
6 Enter the smaller of line 4 or li ne 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I ~'
-
·~
5
6
1 6,283 .
7 Multiply line 6 by the applicable percentage:
• Tax-exempt small employers, multiply line 6 by 25% (.25)
• All other smal l employers, multiply line 6 by 35% (.35) ... ... .... ... . ....... . .... . ... . .. . ... . . .. . .. .. .
8
9
lf line 2 is 10 or less, enter the amount from line 7. Otherwise, see instructions . ....... . . .. . .. .. .. .. .. .. .. 1---'8- + -- -----=4'-'-'-=
0--'-7-=
1..:_.
lf line 3 is $25,000 or less, enter the amount from line 8. Otherwise , see instructions . . ...... . ....... . ...... t-9=--+-- - - -- --=9::..:8:::.9
::...:..
.
1 O Ent er the total amount of any state premium subsidies paid and any state tax credits available to you for
1:::.
0-t-- - - - -- -premiums included on li ne 4 (see instructions) ... . . . . .. . . . . . .... ....... . . ...... . . . ............ . .. . ... . . . . t---:11 Subtract line 10 from line 4. lf zero or less, enter -0-... . . . . . . . . . .... .... . . . . . . . ... . . . . .... ... .. . . .. . ..
1-'1-'1-t--- - - =2..:
4'-!.,..:5:.:2=-0
.::...:...
.
12 Enter the smaller of line 9 or line 11 ...... . . . ...... . . . ........ .. . . ... .. .. . ... . . . ..... . . . ....... . . . .. . . f--712=---,1 -_ _ _ __ 9
:::..:::_
8_::_9_:_
.
13 lf line 12 is zero, skip lines 13 and 14 and go to line 15. Otherwise, enter the number of employees included ' ·,1
on line 1 for whom you paid premiums during the tax year for health insurance coverage under a qualifying i"'·
arrange ment (see instructions). . . . . . . . . . . . . . . . . . ...... . . . . . ...... .... . . . ... ... . .. . . ... . .... . .. ... .. . . .. r--:-1-=3-t- - -- - - -=214 Enter the number of full -ti me equivalent employees you wou ld have entered on line 2 if you only included
employees included on lin e 13 . . . . . . . . . . . . . . . . . . .. . ... . . . . . . . . . . .... . . . ........ . . ..... . .. . ... . . .. .
2
14
15 Credit for sma ll employer hea lth insurance premiums from partnerships, S corporations, cooperatives,
estates, and trusts (see instruc ti ons). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 11-'5- + - -- - -- - 16
Add lines 12 and 15. Cooperatives, estates, and trusts, go to line 17. Tax-exempt sma ll emp loyers,
skip lines 17 and 18 and go to line 19. Partnerships and S corporations, stop here and report this
amount on Schedule K. A ll othe rs, stop here and report this amount on Form 3800, line 4h.
17 Amo unt alloca ted to patrons of the coope rative or beneftciaries of the estate or trust (see instructions) . .
16
989.
1-1_7-+- - - -- - - -
18 Cooperatives, estates, and trusts, subtract line 17 from line 16. Stop here and report thi s amount on Form
3800, line 4h. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .. . 1---'18
=--J- - - - -19 Enter the amount you paid in 2011 for taxes considered payrol l taxes for purposes of this credi t
. .. .. .. .. .....
. .... .. . . ... ... . .
(see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
20 Tax-exempt small employers, enter the s mall er of line 16 or line 19 here and on Form 990 -T, line 44f . ..
20
BAA Fo r Paperwork Reducti on Act Notice, see separ ate instructi ons.
FDIZ940 I L
--
11 ,2 38 .
989 .
Form 8941 (2011)
06/2711 1