| CASH RECEIPTS
Item | From
SCH
# | AMOUNT | CASH DISBURSEMENTS
Item | From
SCH
# | AMOUNT
|
| 39. Dues | | 3 2no | 56. To Officers | 9 | 15-2 0101
|
| 40. Per Capita Tax | | | 57. To Employees | 10 | ~L-101
|
| 41. Fees | | I ILL ~q (6 | 58. Per Capita Tax | | , '1_' 'r
|
| 42. Fines | | | 59. Fees, Fines, Assessments, etc . | | T_
|
| 43. Assessments | | | 60. Office & Administrative Expense | 13 |
|
| 44. Work Permits | | | 61. Educational & Publicity Expense | |
|
| 45. Sale of Supplies | | | 62. Professional Fees | |
|
| 46. Interest | | 3 809 | 63. Benefits | 11 | 20,
|
| 47. Dividends | | | 64. Contributions, Gifts & Grants | 12 |
|
| 48. Rents | | | 65. Supplies for Resale | |
|
| 49. Sale of Investments & Fixed Assets | 6 | | 66. Direct Taxes | | -1~
|
| 50. Loans Obtained | a | | 67. Withholding Taxes | | 0 q
|
| 51. Repayments of Loans Made | 1 | | 68. Purchase of Investments & Fixed Assets | 7 | iq 5,01
|
| 52. On Behalf of Affiliates for Transmittal | | | 69. Loans Made | I |
|
| to Them | | | 70. Repayment of Loans Obtained | 8 |
|
| 53. From Members for Disbursement on | | | 71. To Affiliates of Funds Collected on Their Behalf | |
|
| Their Behalf | | | 72. On Behalf of Individual Members | |
|
| 54. Other Receipts | 14 | | 73. Other Disbursements | 15 |
|
| 55. TOTAL RECEIPTS | | | 74. TOTAL DISBURSEMENTS | | 5-10. Ll 9 a
|
| List below loans to officers, employees, or members which | Loans | | Repayments Received During Period | Loans
|
| at any time during the reporting period exceeded $250 and | Outstanding at | Loans Made | | Outstanding at
|
| list all loans to business enterprises regardless of amount. | Start of Period | During Period | Cash | Other Than Cash | End of Period
|
| (A) | (B) | (C) | (D)(1) | (D)(2) | (E)
|
| 1. Name: | | | | |
|
| Purpose: | | | | |
|
| Security: | | | | |
|
| Terms of Repay ment: | | | | |
|
| 2. Name: | | | | |
|
| Purpose: | | | | |
|
| Security: | | | | |
|
| Terms of Repayment: | | | | |
|
| 3. Totals from additional pages (if any) | | | | |
|
| 4. Totals of loans not listed above | | | | |
|
| 5. Totals of Lines 1 through 4 | | | | |
|
| t t t t
|
| Enter the Totals from Line 5 in Item 27 . Item 69 Item 51 Item 75 Item 27,
|
| Column (A) with Explanation Column (B)
|
| Description
(A) | Amount
(B)
|
| arketable Securities
1. Total Cost |
|
| 2. Total Book Value |
|
| 3. List each marketable security which has a book
value over $1,000 and exceeds 20% of Line 2.
(a) |
|
| (b) |
|
| (c) |
|
| (d) |
|
| Other Investments
4. Total Cost |
|
| 5. Total Book Value |
|
| 6. List each other investment which has a book value
over $1,000 and exceeds 20% of Line 5. Also list
each subsidiary for which separate reports are
attached.
(a) |
|
| (b) |
|
| (c) |
|
| (d) |
|
| (e) Total from additional pages (if any) |
|
| 7. Total of Lines 2 and 5 |
|
| t
Enter the Total from Line 7 in Item 29, Column (B)
|
| SCHEDULE 5 FIXED ASSETS | FILE NUMBER
I
0 1
|
| |
|
| Description
(A) | Cost or
Other Basis
(B) | Total Depreciation
or
Amount Expensed
(C) | Book
Value
(D) | Fair Market
Value
(E)
|
| 1 Land (give location): | | | |
|
| | | |
|
| 2. Totals from additional pages (if any) | | | |
|
| 3. Buildings (give location): | | | |
|
| | | |
|
| 4. Totals from additional pages (if any) | | | |
|
| 5. Automobiles and Other Vehicles | | | | t 5,
|
| 6. Office Furniture and Equipment | | | |
|
| 7. Other Fixed Assets | | | |
|
| 8. Totals of Lines I through 7 | | | |
|
| ......................... Item 30, Column (B)
Enter the Total from Line 8, Column (D) in ..............................
|
| Name
(List all persons who held office during
the reporting period even if they received
no salary or other disbursements.)
(A) | Title
(B) | Status
(C)* | Gross Salary
(before taxes
and other
deductions)
(D) | Allowances
(E) | Disbursements
for
Off icial
Business
(F) | Other
Disbursements
(G) | Total
(H)
|
| 1-F9P'QV_ 7eUUA(5 | Fkes ev S /Ack | C | o L L-1 | 1
S | | |
|
| 2. ro 5ef I+ Q | evs | | | -1,2- Ci | | |
|
| 3. Tk M r;:,5 h R, P, | | | | | | |
|
| | | | | | |
|
| 5.'J~LeO-1710r,_ | V i c a ep'pe_'; | | | | | | so
|
| 6. FPQA,)iK f~,cl_JLL, | Eaz ~D. | | Ci co | | | | 'r
|
| 7. Roo -Zojp~ | Rge, ee~j | 0 | q 90 | | | | ro
|
| 1 | | ~'o 0 | | | |
|
| 9 - To ~4'3 | V I Pr, e- 5 | P | ~_o | | | |
|
| 10. Totals from additional pages (if any) | | | | |
|
| 11. Totals of Lines 1 through 10 | | | | |
|
| 12. Less Deductions |
|
| 13. Net Disbursements | 0~
|
| Enter the Total from Line 13 in Item 56
|
| * Code for Column (C): past officer - P; continuing officer - C; new officer during the reporting period - N.
(If any officer was not elected at a regular election in accordance with your organization's constitution and bylaws, explain in Item 75.
|
| Name
(List all employees who received more
than $10,000 in total disbursements from
your organization and any affiliates.)
(A) | Position
(B) | Name of
Affiliated
Organization
(if applicable)
(C) | Gross Salary
(before taxes
and other
deductions)
(D) | Allowances
(E) | Disbursements
for
Official
Business
(F) | Other
Disbursements
(G) | Total
(H)
|
| 1 - ~_Op' 4 Sr- V'0e'j P'eR | C) FF(C | | 5`5 (.5-o | | | | 5'~ 5_0
|
| 2.1-
OkO 16,j be&,S | | | 4
[-I too | | | | 00
|
| 3. eLJ]E~ PA L | | | | | | | C, ~0
|
| Rep. | | U I in S- | | | | J1 -7
|
| 5. \/4L GP,?KFTTi | | | 150 | | | | So
|
| | | | | | |
|
| 7. | | | | | | |
|
| 8. | | | | | | |
|
| 9. Totals from additional pages (if any) | | | | |
|
| 10. Totals for all employees who, during the reporting
period, received $10,000 or less in total disburse-
ments from your organization and any affiliates | | | | |
|
| 11. Totals of Lines 1 through 10 | | WO | | |
|
| 12. Less Deductions |
|
| 13. Net Disbursements | L~o I
|
| Enter the Total from Line 13 in .................................................... Item 57
|