Form Schedule L (Form 9 Schedule L (Form 9 Transactions with Interested Persons

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Transactions With Interested Persons

SCHEDULE L
(Form 990 or 990-EZ)

2012

if the organization answered
“Yes” on Form 990, Part IV, line 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
▶ Attach to Form 990 or Form 990-EZ. ▶ See separate instructions.

Department of the Treasury
Internal Revenue Service

Open To Public
Inspection

Employer identification number

Name of the organization

Part I

OMB No. 1545-0047

▶ Complete

Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered “Yes” on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

DRAFT AS OF
November 20, 2012
DO NOT FILE
1

(b) Relationship between disqualified person and
organization

(a) Name of disqualified person

(1)
(2)
(3)
(4)
(5)
(6)
2
3

(d) Corrected?

(c) Description of transaction

Yes

Enter the amount of tax incurred by the organization managers or disqualified persons during the year
under section 4958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization

Part II

(b) Relationship
with organization

(c) Purpose of
loan

(d) Loan to or
from the
organization?
To

Part III

.

.

.

.

.

.

.

▶

$
$

Loans to and/or From Interested Persons.
Complete if the organization answered “Yes” on Form 990-EZ, Part V, line 38a or Form 990, Part IV, line 26; or if the
organization reported an amount on Form 990, Part X, line 5, 6, or 22.

(a) Name of interested person

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total

.

No

.

(e) Original
principal amount

(f) Balance due

(g) In default? (h) Approved (i) Written
by board or agreement?
committee?
Yes

From

No

Yes

No

Yes

No

. . . . . . . . . . . . . . . . . . . . . . . .▶ $
Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered “Yes” on Form 990, Part IV, line 27.

(a) Name of interested person

(b) Relationship between interested
person and the organization

(c) Amount of assistance

(d) Type of assistance

(e) Purpose of assistance

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2012

Schedule L (Form 990 or 990-EZ) 2012

Part IV

Page

2

Business Transactions Involving Interested Persons.
Complete if the organization answered “Yes” on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person

(b) Relationship between
interested person and the
organization

(c) Amount of
transaction

(d) Description of transaction

(e) Sharing of
organization’s
revenues?

DRAFT AS OF
November 20, 2012
DO NOT FILE
Yes

No

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)

Part V

Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).

Schedule L (Form 990 or 990-EZ) 2012