Form Schedule J (F 990) Schedule J (F 990) Compensation Information

Caution: DRAFT—NOT FOR FILING
This is an early release draft of an IRS tax form, instructions, or
publication, which the IRS is providing for your information as
a courtesy. Do not file draft forms. Also, do not rely on draft
instructions and publications for filing. We generally do not
release drafts of forms until we believe we have incorporated
all changes. However, in some cases unexpected issues arise,
or legislation is passed, necessitating a change to a draft form
we have posted on IRS.gov. Also, forms generally are subject
to OMB approval before they are officially released. Drafts of
instructions and publications are usually subject to at least
some changes before being officially released.
All early releases of draft forms, instructions, and publications
are available at www.IRS.gov/draftforms. All information
about forms, instructions, and publications is accessible from
www.IRS.gov/formspubs.
If you have any comments on this draft, you can submit them to
us on our IRS.gov page titled Comment on Forms and
Publications, where you may make comments anonymously if
you wish. You can also email us at [email protected]. Please
include the form or publication number in the subject. We
cannot respond to all comments due to the high volume we
receive, but we will carefully consider each suggestion. Please
note that we may not be able to consider many suggestions
until the subsequent revision of the product.

SCHEDULE J
(Form 990)
Department of the Treasury
Internal Revenue Service
Name of the organization

Part I

Compensation Information

OMB No. 1545-0047

2012

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
▶ Complete if the organization answered "Yes" to Form 990,
Part IV, line 23.
▶ Attach to Form 990.
▶ See separate instructions.

Open to Public
Inspection

Employer identification number

DRAFT AS OF
July 5, 2012
DO NOT FILE
Questions Regarding Compensation

Yes

1a

Check the appropriate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Travel for companions
Tax indemnification and gross-up payments
Discretionary spending account

Housing allowance or residence for personal use
Payments for business use of personal residence
Health or social club dues or initiation fees
Personal services (e.g., maid, chauffeur, chef)

b If any of the boxes on line 1a are checked, did the organization follow a written policy regarding payment
or reimbursement or provision of all of the expenses described above? If “No,” complete Part III to
explain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? . . . . .

2

No

1b

2

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization’s CEO/Executive Director. Check all that apply. Do not check any boxes for methods used by a
related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

3

Compensation committee
Independent compensation consultant
Form 990 of other organizations

Written employment contract
Compensation survey or study
Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a, with respect to the filing
organization or a related organization:

4

a Receive a severance payment or change-of-control payment? . . . . . . . . . . . . . . .
b Participate in, or receive payment from, a supplemental nonqualified retirement plan? . . . . . . .
c Participate in, or receive payment from, an equity-based compensation arrangement? . . . . . . .
If “Yes” to any of lines 4a–c, list the persons and provide the applicable amounts for each item in Part III.

5

4a
4b
4c

Only section 501(c)(3) and 501(c)(4) organizations must complete lines 5–9.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

a The organization? . . . . . . . . . . . . . . . . . . . . . . . . . . .
b Any related organization? . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes” to line 5a or 5b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
6
compensation contingent on the net earnings of:

.
.

.
.

.
.

5a
5b

a The organization? . . . . . . . . . . . . . . . . . .
b Any related organization? . . . . . . . . . . . . . . .
If “Yes” to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the
payments not described in lines 5 and 6? If “Yes,” describe in Part III .

.
.

.
.

.
.

6a
6b

8

9

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

organization provide any non-fixed
. . . . . . . . . . . .

Were any amounts reported in Form 990, Part VII, paid or accrued pursuant to a contract that was subject
to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If “Yes,” describe
in Part III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes” to line 8, did the organization also follow the rebuttable presumption procedure described in
Regulations section 53.4958-6(c)?
. . . . . . . . . . . . . . . . . . . . . . . .

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

7

8
9

Schedule J (Form 990) 2012

Schedule J (Form 990) 2012

Part II

DRAFT AS OF
July 5, 2012
DO NOT FILE

Page

2

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)–(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(B) Breakdown of W-2 and/or 1099-MISC compensation

(A) Name and Title

1
2
3
4
5
6

(i) Base
compensation

(D) Nontaxable
benefits

(E) Total of columns
(B)(i)–(D)

(F) Compensation
reported as deferred in
prior Form 990

(i)
(ii)
(i)
(ii)

(i)
(ii)

9

(i)
(ii)

11

(i)
(ii)
(i)
(ii)

12

(i)
(ii)

14

(i)
(ii)
(i)
(ii)

15

(i)
(ii)

16

(i)
(ii)

13

(C) Retirement and
other deferred
compensation

(i)
(ii)

8

10

(iii) Other
reportable
compensation

(i)
(ii)
(i)
(ii)

(i)
(ii)
(i)
(ii)

7

(ii) Bonus & incentive
compensation

Schedule J (Form 990) 2012

DRAFT AS OF
July 5, 2012
DO NOT FILE

Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012