,canada ,rev5ue ,ag5cy                #a

                        ,t#cjaj;,a 7#je7

     ,regi/]$ ,*>;y ,9=m,n ,return
    
        ,sec;n ;,a--,id5tific,n
    
  --,6-plete ? =m1 y w ne$ ! guide call$
    ,-plet+ ! ,regi/]$ ,*>;y ,9=m,n
    ,return1 ,t#djcc;,a4
  --,! ,privacy ,act protects p]sonal
    9=m,n giv5 on ? =m1 : is kept 9 a
    p]sonal 9=m,n bank4
  --,except = yes/no "qs1 if a "q does n
    apply 6yr *>;y1 pl1se l1ve x blank4
  
  ,pl1se atta* a b> code label "h 2f y
mail ? return4 ,if no label1 5t]3

#a4 ,fiscal ,p]iod ,5d+
  7,ye>/,mon?/,"d7 ----
#b4 ,,bn/regi/r,n numb] ----

                                      #a
               ,sec;n ;,a            a#a
7,a#a7 & 7#aejj7 ,has ! *>;y made any
  *anges 6xs gov]n+ docu;ts dur+ !
  fiscal p]iod 7e4g41 lrs pat5t1 >ticles
  ( 9corpor,n1 3/itu;n1 tru/1 or by-
  laws78 7,if yes1 see ! guide47
  ,yes ---- ,no ----
7,a#b7 & 7#aeaj7 ,0 ! *>;y an 9t]nal
  divi.n regulat$ 0! gov]n+ docu;ts (
  ano!r *>;y 7i4e41 x _h no gov]n+
  docu;ts e/abli%+ xs 9dep5d5t exi/;e78
  ,if yes1 :at is ! "n & ,,bn/regi/r,n
  numb] (! o!r *>;y8 ,yes ---- ,no ----

  ,"n ----
  ,,bn/regi/r,n numb]
    7##### ####,,rr####7 ----

7,a#c7 & 7#aedj7 ,0 ! *>;y l9k$ 9 a
  subord9ate way 6a prov9cial1 n,nal1 or
  9t]n,nal organiz,n8 ,if yes1 :at is !
  "n ( ? organiz,n & xs ,,bn/regi/r,n
  numb] 7if applica#78
  ,yes ---- ,no ----
                                      #b
               ,sec;n ;,a            b#a
  ,"n ----
  ,,bn/regi/r,n numb]
    7##### ####,,rr####7 ----

7,a#d7 & 7#aegj7 ,has ! *>;y w.d-up1
  4solv$1 or t]m9at$ op],ns8 7,if yes1
  see ! guide47 ,yes ---- ,no ----
7,a#e7 & 7#aehj7 ,has ! *>;y amalgamat$1
  m]g$1 or 3solidat$ ) ano!r organiz,n8
  7,if yes1 see ! guide47
  ,yes ---- ,no ----

              ,sec;n ;,b--
        ,directors/,tru/ees & ,l
               ,(ficials
    
7,b#a7 & 7#agjj7 ,y m/ atta* a li/ )!
  la/ "n1 f/ "n1 & 9itial ( ea*
  director/tru/ee & l (ficial1 home
  a4ress 79clud+ /reet numb]1 /reet "n1
  c;y1 prov9ce or t]ritory1 & po/al
  code71 posi;n 9 ! *>;y1 :e!r or n !y 7
  a director/tru/ee at ! 5d (! fiscal
  p]iod1 teleph"o numb]1 if !y >e     #c
               ,sec;n ;,b            c#a
  at >m's l5g? f all o!r memb]s (!
  gov]n+ bo>d & _! date ( bir?4 ,only !
  ,public 9=m,n sec;n on ! "w%eet is
  availa# 6! public4 ,! ,3fid5tial 9=m,n
  sec;n is =! ,,ccra's use only & rema9s
  3fid5tial4 ,use ! "w%eet 9clud$ 9 !
  guide or a %eet )! same 9=m,n 9 ! same
  =mat 65t] ? 9=m,n1 & atta* x 6?
  return4 ,see ! guide = an explan,n (!
  t]m .>m's .l5g?4 ,h y atta*$ ! li/
  requir$ abv8 ,yes ---- ,no ----

     ,sec;n ;,c--,programs & ,g5]al
                 ,9=m,n
    
7,c#a7 & 7#ahjj7 ,0 ! *>;y 9active dur+
  ! fiscal p]iod8 ,if yes1 pl1se expla9
  :y 9 ! 8,ongo+ programs0 space 2l4
  ,yes ---- ,no ----
7,c#b7 ,describe h[ ! *>;y c>ri$ \ xs
  *>ita# purposes dur+ ! fiscal p]iod4
  ,give detail$ 9=m,n s a r1d] c cle>ly
  "u/& :at ! *>;y actu,y did 6fulfill xs
  m&ate4 ,describe ! *>;y's .ongo+    #d
               ,sec;n ;,c            d#a
  .programs & .new .programs 9 ! spaces
  provid$ 2l4 ,d .n atta* a4i;nal %eets
  ( pap] or annual reports4 ,d .n 9clude
  a descrip;n ( fundrais+ activities 9 ?
  sec;n4 ,grant-mak+ *>ities %d describe
  ! types ( organiz,ns !y support4
  ,pl1se numb] ea* program4 7,see !
  guide = 9/ruc;ns on h[ 6describe yr
  programs47

  ,ongo+ programs ,7#aj----7'
  ,new programs ,7#e----7'

7,c#c7 ,= programs c>ri$ on 9 ,canada1
  *eck ! appropriate box 6%[ ": !
  programs 7 c>ri$ on4
  7#bjjj7 ---- ,a s+le rural1 c;y1 or
    metropolitan >ea
  7#bjaj7 ---- ,prov9ci,y or t]ritori,y
  7#bjbj7 ---- ,9 m ?an "o prov9ce or
    t]ritory
  

                                      #e
               ,sec;n ;,c             #b
7,c#d7 & 7#bajj7 ,did ! *>;y c>ry on
  programs1 directly or 9directly1
  \tside ,canada8 ,yes ---- ,no ----
  ,if yes1 7 any c>ri$ \3
    7#baaj7--0employees or volunte]s (!
      *>;y8 ,yes ---- ,no ----
    7#babj7--"u ag5cy agree;t1 3tract1
      jo9t-v5ture1 or simil> >range;ts8
      ,yes ---- ,no ----
    7#bacj7--"? gifts 6qualifi$ donees8
      ,yes ---- ,no ----
    7#badj7--0o!r m1ns8
      ,yes ---- ,no ----
7,c#e7 ,= programs ! *>;y manag$
  directly1 \tside ( ,canada1 li/ !
  c.tries or regions ": programs 7 c>ri$
  on4 ,d n 9clude c.tries or regions ":
  programs 7 manag$ 0a qualifi$ donee4
  ,7#aj----7'
7,c#f7 & 7#bcjj7 ,did ! *>;y issue
  s*ol>%ips1 burs>ies1 aw>ds1 prizes1 or
  honor>ia 6an 9dividual dur+ ! fiscal
  p]iod8 ,yes ---- ,no ----
                                      #f
               ,sec;n ;,c            a#b
7,c#g7 & 7#bdjj7 ,a *>;y may pursue
  political activities t >e non-"pisan1
  relat$ 6xs *>ita# purposes1 & limit$ 9
  ext5t4 ,dur+ ! fiscal p]iod1 did !
  *>;y c>ry \ political activities or
  provide assi/.e 6ano!r organiz,n 6c>ry
  \ political activities8 7,see ! guide
  = 9=m,n on political activities47
  ,yes ---- ,no ----
7,c#h7 ,if ! *>;y c>ri$ on fundrais+
  activities1 *eck all fundrais+ me?ods
  t x us$ dur+ ! fiscal p]iod4
  7#bejj7 ---- ,adv]tise;ts/po/]s/-
    fly]s/radio or ,,tv -m]cials
  7#beaj7 ---- ,auc;ns
  7#bebj7 ---- ,b+o/cas9o ni<ts
  7#becj7 ---- ,collec;n plates/boxes
  7#bedj7 ---- ,door-to-door solicit,n
  7#beej7 ---- ,draws/lott]ies
  7#befj7 ---- ,fundrais+ d9n]s/galas/-
    3c]ts
  7#begj7 ---- ,fundrais+ sales 7e4g41
    cookies1 *ocolate7
  7#behj7 ---- ,mail campaigns        #g
               ,sec;n ;,c            b#b
  7#beij7 ---- ,plann$-giv+ programs
  7#bfjj7 ---- ,t>get$ corporate
    don,ns/sponsor%ips
  7#bfaj7 ---- ,t>get$ 3tacts
  7#bfbj7 ---- ,teleph"o solicit,ns
  7#bfcj7 ---- ,t\rna;ts/sport+ ev5ts
  7#bfdj7 ---- ,walk-a-?ons/bike-a-?ons
    7etc47
  7#bfej7 ---- ,o!r
  7#bffj7 ,specify3 ----
  
7,c#i7 & 7#bgjj7 ,did ! *>;y use
  9c5tive-bas$ -p5s,n 7e4g41 bonuses1
  -mis.ns1 f9d]'s fees1 honor>ia7 =
  fundrais]s8 ,if yes1 7 ^! 9c5tives pd
  to3 ,yes ---- ,no ----
    7#bgaj7--3tract$ fundrais]s8
      ,yes ---- ,no ----
    7#bgbj7 /aff or volunte]s8
      ,yes ---- ,no ----
7,c#aj7 & 7#bhjj7 ,did ! *>;y *>ge fees
  =1 or o!rwise rcv regul> rev5ue f gds1
  s]vices1 or ! use (! *>;y's assets8
  ,yes ---- ,no ----                  #h
               ,sec;n ;,c            c#b
7,c#aa7 & 7#bijj7 ,did ! *>;y make gifts
  6qualifi$ donees8 ,yes ---- ,no ----

  ,if yes1 y .m/ atta* a li/ )! "n ( ea*
  qualifi$ donee & xs loc,n1
  ,,bn/regi/r,n numb]1 ! total am.t (!
  gift =! fiscal p]iod1 ! am.t1 if any1
  ( specifi$ gifts1 & :e!r or n x is an
  associat$ *>;y4 ,li/ ! qualifi$ donees
  9 ! ord] (! total am.t (! gifts made1
  />t+ )! l>ge/4 ,use ! "w%eet 9clud$ 9
  ! guide or a %eet )! same 9=m,n 9 !
  same =mat & atta* x 6? return4
7,c#ab7 ,if ! *>;y rcvd non-ca% gifts
  7gifts 9 k9d7 = : x issu$ tax
  receipts1 *eck all ! types ( gifts t
  apply4
  7#cjjj7 ---- ,>t"w/w9e/jewell]y
  7#cjaj7 ---- ,build+ mat]ials
  7#cjbj7 ---- ,clo?+/furniture/food
  7#cjcj7 ---- ,vehicles
  7#cjdj7 ---- ,cultural prop]ty
  7#cjej7 ---- ,ecological prop]ty
                                      #i
               ,sec;n ;,c            d#b
  7#cjfj7 ---- ,ma*9]y/equip;t 79clud+
    -put]s/s(tw>e7
  7#cjgj7 ---- ,h$ge funds/life 9sur.e
    policies
  7#cjhj7 ---- ,publicly-trad$
    securities/mutual funds
  7#cjij7 ---- ,privately-held
    securities
  7#cajj7 ---- ,o!r
  7#caaj7 ,specify3 ----
  
         ,sec;n ;,d--,comp5s,n
    
,note3
  ,-p5s,n 9cludes .all =ms ( remun],n
  7e4g41 sal>ies1 fees1 & honor>ia7 &
  b5efits 7e4g41 p]sonal use (a c> or
  (fice space74

7,d#a7 & 7#cfjj7 ,on av]age1 h[ _m
  p]man5t1 full-"t1 -p5sat$ posi;ns did
  ! *>;y h 9 ! fiscal p]iod8 ----
7,d#b7 ,=! five hi<e/ -p5sat$ posi;ns
  9dicate ! .numb] ( posi;ns 9 ea*   #aj
               ,sec;n ;,d            e#b
  (! foll[+ .annual -p5s,n categories4
  ,9clude only ^? posi;ns t >e .p]man5t1
  .full-"t .posi;ns4
  7#cgjj7 ---- 4#a-4#ci1iii
  7#cgaj7 ---- 4#dj1jjj-4#gi1iii
  7#cgbj7 ---- 4#hj1jjj-4#aai1iii
  7#cgcj7 ---- 4#abj1jjj & ov]
7,d#c7 & 7#chjj7 ,on av]age1 h[ _m "p-"t
  or "p-ye> employees did ! *>;y employ
  9 ! fiscal p]iod8 ----
7,d#d7 & 7#chej7 ,:at 0 ! total
  exp5diture on -p5s,n = "p-"t or "p-ye>
  employees 9 ! fiscal p]iod8 4#j.jj
7,d#e7 & 7#cijj7 ,did ! *>;y -p5sate any
  ( xs directors/tru/ees or l (ficials1
  dur+ ! fiscal p]iod8
  ,yes ---- ,no ----
7,d#f7 & #ciej7 ,except = -p5s,n1 did !
  *>;y1 directly or 9directly1 transf]
  any "p ( xs 9come or assets
  69dividuals or organiz,ns n at >m's
  l5g? 6! *>;y8 ,yes ---- ,no ----

                                     #aa
      ,sec;n ;,e--,f9ancial ,9=m,n    #c
    
7,e#a7 & 7#djbj7 ,0 ! f9ancial 9=m,n
  report$ 2l prep>$ on an a3rual or ca%
  basis8
  ,a3rual ---- ,ca% ----

7,e#b7 ,pl1se %[ figures 6! ne>e/ .s+le
  .doll>4 ,d n %[ c5ts4 ,see ! guide =
  an explan,n (! t]ms4

  ,assets
7#dajj7 ,ca%1 bank a3.ts1 & %ort-
  t]m 9ve/;ts """"""""""""""""""" 4#----
7#daaj7 ,am.ts receiva# f .non-
  >m's l5g? "pies """"""""""""""" 4#----
7#dabj7 ,am.ts receiva# f all
  o!rs """""""""""""""""""""""""" 4#----
7#dacj7 ,9ve/;ts 9 .non->m's l5g?
  "pies """"""""""""""""""""""""" 4#----
7#dadj7 ,l;g-t]m 9ve/;ts """""""" 4#----
7#daej7 ,9v5tories """""""""""""" 4#----
7#dafj7 ,capital assets 7at co/
  or fair m>ket value7 """""""""" 4#----
                                     #ab
               ,sec;n ;,e            a#c
7#dagj7 ,o!r assets """"""""""""" 4#----
7#dbjj7 .,total .assets 7add l9es
  #dajj 6#dagj7 """"""""""""""""" 4#----

  ,liabilities
7#dcjj7 ,a3.ts paya# & a3ru$
  liabilities """"""""""""""""""" 4#----
7#dcaj7 ,def]r$ rev5ue """""""""" 4#----
7#dcbj7 ,am.ts [+ 6.non->m's l5g?
  "pies """"""""""""""""""""""""" 4#----
7#eccj7 ,o!r liabilities """""""" 4#----
7#dcej7 .,total .liabilities 7add
  l9es #dcjj 6#dccj7 """""""""""" 4#----

7#dbej7 ,am.t 9clud$ 9 l9es
  #daej1 #dafj1 & #dagj n us$ 9
  *>ita# programs """"""""""""""" 4#----

7,e#c7 ,pl1se %[ figures 6! ne>e/
  .s+le .doll>4 ,d n %[ c5ts4
  ,see ! guide = an explan,n (!
  t]ms4

                                     #ac
               ,sec;n ;,e            b#c
  ,rev5ue
7#dejj7 ,total eligi# am.t
  ( tax-receipt$ gifts """ 4#----
7#deaj7 ,total am.t
  rcvd f o!r
  regi/]$ *>ities """""""" 4#----
7#debj7 ,total
  specifi$ gifts
  9clud$ 9 l9e
  #deaj """"""""""" 4#----
7#debe7 ,total
  5dur+ prop]ty
  9clud$ 9 l9e
  #deaj 7,see !
  guide47 """"""""" 4#----
7#decj7 ,total o!r
  gifts """""""""""""""""" 4#----
7#dedj7 ,rev5ue f
  f$]al gov]n;t """ 4#----
7#deej7 ,rev5ue f
  prov9cial/t]ritorial
  gov]n;ts """""""" 4#----

                                     #ad
               ,sec;n ;,e            c#c
7#defj7 ,rev5ue f
  municipal/
  regional gov]n;ts 4#----
7#degj7 ,total
  rev5ue f gov]n;t
  7add l9es #dedj1
  #deej1 & #defj7 """""""" 4#----
7#dehj7 ,9t]e/ &
  9ve/;t 9come """"""""""" 4#----
  ,proce$s f
  4posi;n ( assets
7#deij7 gross """"" 4#----
7#dfjj7 net """""""""""""" 4#----
7#dfaj7 ,r5tal 9come 7l& &
  build+s7 """"""""""""""" 4#----
7#dfbj7 ,memb]%ips1 dues1
  & associ,n fees 7non
  tax-receipt$7 """""""""" 4#----
7#dfcj7 ,total rev5ue f
  fundrais+ """""""""""""" 4#----
7#dfdj7 ,total rev5ue f
  sale ( gds & s]vices
  7except 6gov]n;t7 """""" 4#----
                                     #ae
               ,sec;n ;,e            d#c
7#dfej7 ,o!r rev5ue """""" 4#----
7#dgjj7 ,total rev5ue 7add
  l9es #dejj1 #deaj1
  #decj1 #degj1 #dehj1 &
  #dfjj 6#dfej7 """"""""""""""""" 4#----

  ,exp5ditures 7,5t] all exp5ditures1
    :e!r or n on *>ita# programs7
7#dhjj7 7,adv]tis+ &
  promo;n """""""""""""""" 4#----
7#dhaj7 ,travel & vehicle  4#----
7#dhbj7 ,9t]e/ & bank
  *>ges """""""""""""""""" 4#----
7#dhcj7 ,lic;es1
  memb]%ips1 & dues """""" 4#----
7#dhdj7 ,(fice supplies &
  exp5ses """""""""""""""" 4#----
7#dhej7 ,o3upancy co/s """ 4#----
7#dhfj7 ,profes.nal &
  3sult+ fees """""""""""" 4#----
7#dhgj7 ,$uc,n & tra9+ =
  /aff & volunte]s """"""" 4#----

                                     #af
               ,sec;n ;,e            e#c
7#dhhj7 ,sal>ies1 wages1
  b5efits1 & honor>ia """" 4#----
7#dhij7 ,donat$ & pur*as$
  supplies & assets exp5s$
  =! fiscal p]iod """""""" 4#----
7#dijj7 ,amortiz,n (
  capitaliz$ assets """""" 4#----
7#diaj7 ,rese>* grants &
  s*ol>%ips z "p ( *>ita#
  programs """"""""""""""" 4#----
7#dibj7 ,o!r exp5ditures   4#----
7#diej7 ,total exp5ditures
  2f gifts 6qualifi$
  donees 7add l9es #dhjj
  6#dibj7 """"""""""""""""""""""" 4#----

7#ejjj7 ,total *>ita#
  programs exp5ditures
  9clud$ 9 l9e #diej """"" 4#----
7#ejaj7 ,total manage;t &
  adm9i/r,n exp5ditures
  9clud$ 9 l9e #diej """"" 4#----

                                     #ag
               ,sec;n ;,e            f#c
7#ejbj7 ,total fundrais+
  exp5ditures 9clud$ 9 l9e
  #diej """""""""""""""""" 4#----
7#ejcj7 ,total political
  activ;y exp5ditures
  9clud$ 9 l9e #diej """"" 4#----
7#ejdj7 ,total o!r
  exp5ditures 9clud$ 9 l9e
  #diej """""""""""""""""" 4#----
7#ejej7 ,total gifts 6qualifi$
  donees exclud+ 5dur+ prop]ty "" 4#----
7#ejfj7 ,total 5dur+ prop]ty
  transf]r$ 6qualifi$ donees
  7,see ! guide47 """"""""""""""" 4#----
7#ejgj7 ,total specifi$ gifts
  6qualifi$ donees 7,see !
  guide47 """"""""""""""""""""""" 4#----
7#eajj7 ,total exp5ditures 7add
  l9es #diej1 #ejej1 #ejfj &
  #ejgj7 """""""""""""""""""""""" 4#----



                                     #ah
       ,sec;n ;,f--,o!r ,requir$      #d
                 ,9=m,n
    
7,f#a7 & 7#edjj7 ,:at 7 ! total
  exp5ditures on programs \tside
  ,canada dur+ fiscal p]iod1
  exclud+ gifts 6qualifi$ donees8 4#----
7,f#b7 ,if ! *>;y reta9$ 3tract$
  fundrais]7s71 5t]3
  7#edej7 a4 ! gross rev5ues
    collect$ 0! fundrais]7s7 on
    2half (! *>;y """"""""""""""" 4#----
  7#edfj7 b4 ! am.ts pd 6&/or
    reta9$ 0! fundrais]7s7 """""" 4#----
  7#edgj7 c4 ! net fundrais+
    rev5ue rcvd 0! *>;y 7l9e
    #edej m9us l9e #edfj7 """"""" 4#----
7,f#c7 ,if ! *>;y has writt5
  p]mis.n 6a3umulate prop]ty1
  5t]3
  7#eejj7--! am.t a3umulat$ =!
    fiscal p]iod1 9clud+ 9come
    e>n$ =! fiscal p]iod on
    previ\sly a3umulat$ funds """ 4#----
                                     #ai
               ,sec;n ;,f            a#d
  7#eeaj7--! am.t 4burs$ =!
    fiscal p]iod =! specifi$
    purpose we h grant$ p]mis.n = 4#----
  7#eebj7--! am.t deem$ 6be a
    tax-receipt$ gift =! fiscal
    p]iod """"""""""""""""""""""" 4#----
7,f#d7 ,(! tax-receipt$ gifts
  rcvd 0! *>;y =! fiscal p]iod1
  5t]3
  7#efjj7--! total eligi# am.t (
    tax-receipt$ non-ca% gifts
    7gifts 9 k9d7 """"""""""""""" 4#----
  7#efaj7--! total eligi# am.t (
    tax-receipt$ tui;n fees """"" 4#----
  7#efdj7--! total eligi# am.t (
    tax-receipt$ 5dur+ prop]ty "" 4#----
7,f#e7 & 7#egaj7 ,5t] ! am.t1 if
  any1 ( 5dur+ prop]ty sp5t 9 !
  fiscal p]iod4 7,see ! guide47   4#----
7,f#f7 & 7#egbj7 ,5t] ! capital
  ga9s f ! 4posi;n ( 5dur+
  prop]ty 9 ! fiscal p]iod4 7,see
  ! guide47 """"""""""""""""""""" 4#----
                                     #bj
               ,sec;n ;,f            b#d
7,f#g7 & 7#egcj7 ,is ! *>;y
  claim+ an am.t t is less ?an !
  maximum capital ga9s reduc;n8
  7,see ! guide47
  ,yes ---- ,no ----
  7#egdj7 ,if yes1 5t] ! am.t f
    l9e #aa ( =m ,t#abei4 7,see !
    guide47 """"""""""""""""""""" 4#----
7,f#h7 & 7#egej7 ,if ! *>;y is
  tak+ a special reduc;n1 : we h
  approv$1 6xs 4burse;t quota1
  5t] ! special reduc;n am.t =!
  fiscal p]iod """""""""""""""""" 4#----
7,f#i7 & 7#ehjj7 ,did ! *>;y
  acquire a non-qualify+ secur;y
  or all[ a donor 6use any (!
  *>;y's prop]ty "u ! circum/.es
  describ$ 9 ! guide dur+ !
  fiscal p]iod8
  ,yes ---- ,no ----
7,f#aj7 ,9dicate ! av]age value (
  prop]ty n us$ = *>ita#
  activities or adm9i/r,n dur+3
                                     #ba
               ,sec;n ;,f            c#d
  7#eijj7--! #bd mon?s 2f ! 2g9n+
    (! fiscal p]iod """"""""""""" 4#----
  7#eiaj7--! #bd mon?s 2f ! 5d (!
    fiscal p]iod """""""""""""""" 4#----
  
      ,sec;n ;,g--,= ,f.d,ns ,only
    
,note3
  ,see ! guide = an explan,n (! t]ms &
  require;ts ( ? sec;n4

7,g#a7 & 7#fjjj7 ,9 ! fiscal p]iod1 did
  ! f.d,n acquire 3trol (a %>e-capital
  or =-pr(it corpor,n8
  ,yes ---- ,no ----
7,g#b7 & 7#fajj7 ,did ! f.d,n 9cur debts
  at any "t dur+ ! fiscal p]iod o!r ?an
  = curr5t op]at+ exp5ses1 9 pur*as+ or
  sell+ 9ve/;ts1 or 9 adm9i/]+ *>ita#
  programs8 ,yes ---- ,no ----
7,g#c7 & 7#faej7 ,= private f.d,ns only3
  ,at any "t dur+ ! fiscal p]iod1 did !
  f.d,n hold any %>es1 "rs 6acquire s*
                                     #bb
               ,sec;n ;,g            d#d
  %>es1 or debts [+ 6x t meet ! def9i;n
  (a non-qualifi$ 9ve/;t8
  ,yes ---- ,no ----

         ,sec;n ;,h--,c]tific,n
    
7,h#a7 ,6be -plet$ 0a director/tru/ee or
  l (ficial (! *>;y4 ,x is a s]i\s (f;e
  "u ! ,9come ,tax ,act 6provide false
  or deceptive 9=m,n4

  ,i c]tify t ! 9=m,n giv5 on ? =m1 !
basic 9=m,n %eet1 & any atta*;ts is1 6!
be/ ( my k1 correct1 -plete1 & curr5t4

,"n 7pl1se pr9t7 ----
,signature ----
,posi;n 9 *>;y ----
,date sign$ ----




                                     #bc
      ,sec;n ,i--,3fid5tial ,data    e#d
    
7,i#a7 ,physical loc,n 7a4ress7 (! *>;y
  7,d n use rural r\te or po/ (fice box
  numb]s47
  ,numb]1 /reet1 a"p;t numb]1 or lot &
    3ces.n numb] ----
  ,c;y ----
  ,prov9ce or t]ritory ----
  ,po/al code3 ----
  
7,i#b7 ,loc,n (! *>;y's books & records
  ,numb]1 /reet1 a"p;t numb]1 or lot &
    3ces.n numb] ----
  ,c;y ----
  ,prov9ce or t]ritory ----
  ,po/al code3 ----
  
7,i#c7 ,"n & a4ress (! p]son :o -plet$ ?
  return
  ,"n ----
  ,firm "n 7if applica#7 ----
  

                                     #bd
               ,sec;n ;,i            f#d
  ,numb]1 /reet1 a"p;t numb]1 or lot &
    3ces.n numb] ----
  ,c;y ----
  ,prov9ce or t]ritory ----
  ,po/al code3 ----
  ,ph"o numb] ----
  ,fax numb] ----
  















                                     #be