Form 8734 (Rev. 1-2004) Page 2
12
If you are an organization that normally receives a substantial part of your support from a governmental unit or from the general
public, complete lines 12a through 12f. (Sections 509(a)(1) and 170(b)(1)(A)(vi)). If you want the IRS to compute your public
support test as a section 509(a)(1) and 170(b)(1)(A)(vi) organization, complete only lines 12a and 12b.
a Enter 2% of amount in column (f), line 10
䊳
12a
b
Attach a list showing the name of and amount contributed by each person (other than a governmental
unit or publicly supported organization) whose total gifts for Year 5 through Year 1 exceeded the
amount shown in line 12a. Enter the total of all these excess amounts
䊳
12b
c Total support for section 509(a)(1) test: Enter line 10, column (f)
䊳
12c
d Add: Amounts from
column (f) for lines:
4 5
8 12b
䊳
12d
e Public support (line 12c minus line 12d total)
䊳
12e
f
Public support percentage (line 12e (numerator) divided by line 12c (denominator))
䊳
12f
%
13
If you are an organization that normally receives: (1) more than 33
1
⁄3% of your support from contributions, membership fees,
and gross receipts from activities related to your exempt functions, and (2) no more than 33
1
⁄3% of your support from gross
investment income and net unrelated business taxable income from businesses acquired by the organization after June 30,
1975, complete lines 13a through 13h. (Section 509(a)(2)). If you want the IRS to compute your public support test as a
section 509(a)(2) organization, complete only lines 13a and 13b.
a
For amounts included in lines 1, 2, and 3 that were received from a “disqualified person,” attach a list showing the name of,
and total amounts received in each year from, each “disqualified person.” Enter the sum of such amounts for each year:
(Year 5) (Year 4) (Year 3) (Year 2) (Year 1)
b For any amount included in line 3 that was received from each person (other than “disqualified persons”), attach a list showing
the name of, and amount received for each year, that was more than the larger of (1) the amount on line 11 for the year or
(2) $5,000. (Include in the list organizations as well as individuals.) After computing the difference between the amount received
and the larger amount described in (1) or (2), enter the sum of these differences (the excess amounts) for each year:
(Year 5) (Year 4) (Year 3) (Year 2) (Year 1)
c Add: Amounts from column (f) for lines: 1
2
3
6
7
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13c
d
Add: Line 13a total and line 13b total
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13d
e
Public support (line 13c total minus line 13d total)
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13e
f
Total support for section 509(a)(2) test: Enter amount from line 9, column (f)
䊳
13f
g Public support percentage (line 13e (numerator) divided by line 13f (denominator))
䊳
13g
%
h Investment income percentage (line 4, column (f) (numerator) divided by line 13f (denominator))
䊳
13h
%
14 Unusual Grants: For an organization described in line 12 or 13 that received any unusual grants during Year 5 through Year
1, attach a list showing for each year the name of the contributor, the date and amount of the grant, and a brief description
of the nature of the grant. Do not include these grants in line 1.
List the amount of unusual grants excluded for each year below.
(Year 5)
(Year 4) (Year 3) (Year 2) (Year 1)
15 Please list the name and telephone number of an officer, director, or trustee who can be contacted during business hours if
we need more information. If someone other than an officer, director, or trustee will represent the organization, attach a properly
completed Form 2848, Power of Attorney.
Name:
Type or print name and title.
Phone:
(
)
Fax Number (if available):
(
)
Please
Sign
Here
I declare under the penalties of perjury that I am authorized to sign this form on behalf of the above organization and that I have examined this form,
including the accompanying attachments, and to the best of my knowledge it is true, correct, and complete.
䊳
Signature of officer, director, or trustee Date
䊳
Type or print name and title or authority of signer
Form 8734 (Rev. 1-2004)
