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Form LDING TOGETHER F THE TRIANGLE
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<br />2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements,
<br />filed for the calendar year ending with or within the year covered by this return
<br />b lf at least one is reported on line 2a, did the organization file all required federal employment tax returns?
<br />Note: lf the sum of lines 1 a and 2a is greater than 250, you may be require d lo s-1;1s (see instructions) ....
<br />Did the organization have unrelated business gross income of $1 ,000 or more during the year?
<br />lf "Yes,"hasitfiledaFormgg0-Tforthisyear? tf "No"toline3b,provideanexplanationonSchecluleO
<br />At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a
<br />financial accountinaforeigncountry(suchasabankaccount,securitiesaccount,orotherfinancial account)? ....
<br />lf "Yes," enterthe name of theforeign countrV )
<br />See instructions forfiling requirements for FinCEN Form 114, Repod of Foreign Bank arrcl Financial Accounts (FBAR).
<br />Was the organization a party to a prohibited tax shelter transaction at any time during the lax year?
<br />Did any taxable party notify the organization that it was or is a parly to a prohibited tax shelter transaction?
<br />lf "Yes" to line 5a or 5b, did the organizatlon file Form B886.T?
<br />Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit
<br />any contributior.rs that were not tax deductible as charitable contributions?
<br />lf "Yes," did the organization include with every solicitation an express statement that such contributjons or gifts
<br />were not tax deductible?
<br />7 organizalions that may receive deductible contributions under section 170(c).
<br />a Did the organization receive a payment jn excess ol $75 made partly as a contributi0n and partly for goocls ancl services providecl t0 the payor?b lf"Yes,"didtheorganizationnotifythedonorofthevalueofthegoodsorseruicesprovided?
<br />c Did the organization sell, exchange, or otherwise dispose of tangible personal propefty for which it was required
<br />lf "Yes," indicate the number of Forms 8282 filed during the year 7d
<br />Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
<br />Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefjt contract?
<br />lftheorganizationrecetvedacontributionofqualifiedintellectual property,didtheorganizationfileFormBgggasrequired?..
<br />lf the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1OSB-C?
<br />Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the
<br />sponsoring organization have excess business holdings at any time during fl-re year?
<br />Sponsoring organizations maintaining donor advised funcls.
<br />Did the sponsoring organization make any taxable distributrons under section 4966?
<br />Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?
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<br />Section 501(c)(7) organizations. Enter:
<br />lnrtiation fees and capital contributtons included on parl Vlll, line 12 .........
<br />Gross receipts, included on Form 990, part Vlll. line 12, for public use of club facilities
<br />Section 501(cX12) organizations. Enter:
<br />Gross income from members or shareholders 11a
<br />Gross income from other sources (Do not net amounts due or paid to other sources against
<br />amounts due or received from them.)
<br />'l2a Section gaT@)(1) non-exempt charitable trusts. ls the organization filing Form ggo in ljeu ol Fotm 1o41./b lf "Yes," enter the amount of tax-exempt interest received or accrued during the year I ,zu13 Section 501(c)(29) qualified nonprofit health insurance issuers.
<br />a ls the organization licensed to issue qualified health plans in more than one state?
<br />Note: See the instructions for additional information the organization must report on Schedule o.
<br />Enter the amount of reserves the organization is required to maintain by the states in which the
<br />organization is licensed to issue qualified health plans
<br />Enter the amount of reserves on hand
<br />Did the organization recerve any payments for indoortanning services clurrng the raxyear?
<br />l{'Yes,"hasitfiledaFormT20toreponthesepayments? tf "No,,,provicleanexplanationonScheduteO
<br />ls the organization subject to the section 4960 tax on payment(s) of more than $i,o00,oOO in remuneration or
<br />excess parachute payment(s) during the year?
<br />lf "Yes." see instructions and file Form 4720. Schedule N.
<br />ls the organization an educational institution subiect to the section 4968 excise tax on net investment income?
<br />"Yes. "
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<br />032005 12-23 20
<br />DocuSign Envelope ID: E86DD11C-7C3F-4DD6-97F0-CADB5D52D35A
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