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C O j C= " O@ bH 0 H e= M ' M D ? M ; ? k k k k k k k 7H 7H k k k H k k k k M k k k k k k k k k : PSK LLPForm 990-EZ ChecklistPlease also complete Form 990-EZ Supplemental Schedules Checklist
Revised 2/2015
Name of Organization
Organization exempt status (please circle) 501(c)3, 501(c)4, 501(c)5, 501(c)6, 501(c)7
What is your website address, if any?
Phone number
Describe your organizations primary exempt purpose.
Describe in sufficient detail, the exempt purpose of the organizations top three program services. If applicable, include specific measurements and/or statistical information (such asnumber of clients served, days care provided, number of sessions or events held, etc.)
During the year, did the organization engage in any activity not previously reported to the IRS?
If yes, please describe those activities.
Did the organization make any changes to the organizing or governing documents that have not been reported to the IRS?
If yes, provide a copy of those changes.
Did your organization have unrelated business gross income of $1,000 or more?
If yes, describe what kind of income.
Did your organization have any lobbying and political expenditures?
If yes, did your organization report to the members the portion of their membership dues that were allocable to the political or lobbying activity?
If no, then see Schedule C Checklist.
Did the organization incur any direct or indirect political expenditure?
If yes, enter the dollar amount of expenditures.
If yes, has the organization filed Form 1120-POL?
Was there a liquidation, dissolution, termination, or substantial contraction of the organizations operations?
If yes, see Schedule N Checklist.
Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employees or were any such loans made in a prior year and still unpaid at the beginning of the tax year covered by this return?
If yes, see Schedule L Checklist.
For 501(c)(3) organizations, enter the amount of tax, if any, imposed during the year under the following Internal Revenue Code sections:
Section 4911
Section 4912
Section 4955
Enter the amount of tax imposed on the organizations managers or disqualified persons during the year under sections 4912, 4955, and 4958.
Enter the amount of tax imposed on the organizations managers or disqualified persons that was reimbursed by the organization.
For 501(c)(3) and (4) organizations, did the organization engage is any excess benefit transaction during the year, or did it become aware of an excess benefit transaction from a prior year?
If yes, see Schedule L Checklist.
At any time during the tax year, was the organization a party to a prohibited tax shelter transaction?
For 501(c)(7) organizations how much in gross revenue did you collect for the following:
Initiation fees and capital contributions?
Public use of club facilities?
List the name, address, and phone number of the person in whose care the books are kept.
At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country?
If yes, what country?
The organization may also be required to file IRS Form TD F 90-22.1.
At any time during the calendar year, did the organization maintain an office outside of the United States? If yes, what country?
Did the organization maintain any donor advised funds?
If yes, the organization will be required to file Form 990 not Form 990-EZ.
Is any related organization a controlled entity?
If yes, the organization is required to file Form 990 not Form 990-EZ.
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office?
If yes, see Schedule C Checklist.
Did the organization engage in lobbying activities?
If yes, see Schedule C Checklist.
Is the organization operating a school?
If yes, see Schedule E Checklist.
Did the organization make any transfers to an exempt non-charitable related organization?
If yes, was the related organization(s) a section 527 organization?
Provide a list of the officers, directors, trustees, and key employees for the tax year and provide the following information for each one listed:
Name
Title and average hours per week devoted to position
Compensation, if not paid, enter -0-
Deferred compensation and contributions to employee benefit plans
Expense account and other allowances
For any employee (s) who received more than $100,000 of compensation from the organization, please provide the following information:
Name
Title and average hours per week devoted to the position
Compensation
Deferred compensation and contributions to employee benefit plans
Expense account and other allowances
For the five highest compensated independent contractors that received more than $100,000 from the organization, please provide the following information:
Name and address
Type of service rendered
Amount of compensation
Did the organization receive during the year, an aggregate of $5,000 or more from any one contributor?
If yes, please provide a list of those donors (which include individuals, fiduciaries, partnerships, corporations, associations, trusts, foundations, and exempt organizations). That list should include:
Name of donor, address, and total amount donated for the year
If the donation was other than cash, note what the non-cash donation consisted of and the fair market value and date received if property or stock.
Indicate if the donor is a family member of an officer or key employee
Did the organization have gross revenue from fundraising events and activities or from gaming of greater than $15,000?
If yes, see Schedule G Checklist.
Did the organization make grants to an organization or individual during the year of greater than $5000?
If yes, provide the following information:
Be specific in the type activity that warranted the grant payment.
The grantees name
The grantees address, but only for organizations (not individuals)
The amount given
The relationship of the grantee (individuals only), if any, to any person or corporation with an interest in the organization.
Colleges, universities, and schools reporting scholarships or other financial assistance, please provide the following instead of the specific information listed above.
List each type of financial aid provided
Indicate the number of individuals who received aid
Specify the aggregate dollar amount
If the organization gives property other than cash and measures the award or grant by the fair market value of the property, provide the following:
Description and book value of the property
How the organization determined the book value
How the organization determined the fair market value
Date of the award or grant
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