| A. Statement of Revenue and Expenses |
| | Current year | 3 prior years or proposed budget 2 years | |
| | (a) 1997 | (b) 1998 | (c) 1999 | (d) 19__ | (e) Total |
| R | 1 Gifts, grants and contributions received (not
including unusual grants - see pages 5 and 6 of the
instructions) | $1,000 | $2,680 | $9,680 | | $13,360 |
| e | 2 Membership fees received | | | | | |
| v | 3 Gross investment income (see instructions for
definition) | | | | | |
| e | 4 Net income from organization's unrelated business
activities not included on line 3 | | | | | |
| n | 5 Tax revenue levied for and either paid to or spent on
behalf of the organization | | | | | |
| u | 6 Value of services or facilities furnished by a
governmental unit to the organization without charge
(not including the value of services or facilities
generally furnished the public without charge) | | | | | |
| e | 7 Other income (not including gain or loss from sale of
capital assets) (attach schedule) | | | | | |
| 8. Total (add lines 1 through 7) | $1,000 | $2,680 | $9,680 | | $13,360 |
| 9. Gross receipts from admissions, sales of
merchandise or services, or furnishing of facilities in
any activity that is not an unrelated business within
the meaning of section 513. Include related cost of
sales on line 22. | | | | | |
| 10 Total (add lines 8 and 9) | $1,000 | $2,680 | $9,680 | | $13,360 |
| 11 Gain or loss from sale of capitol assets (attach
schedule) | | | | | |
| 12 Unusual grants | | | | | |
| 13 Total revenue (add lines 10 through 12) | $1,000 | $2,680 | $9,680 | | $13,360 |
| E | 14 Fundraising expenses | $817 | $721 | $571 | | |
| x | 15 Contributions, gifts, grants, and similar amounts
paid (attach schedule) | | $1,750 | $8,750 | | |
| p | 16 Disbursements to or for benefit of members (attach
schedule) | | | | | |
| e | 17 Compensation of officers, directors, and trustees
(attach schedule) | | | | | |
| n | 18 Other salaries and wages | | | | | |
| s | 19 Interest | | | | | |
| e | 20 Occupancy (rent, utilities, etc.) | | | | | |
| s | 21 Depreciation and depletion | | | | | |
| 22 Other (attach schedule) | | | | | |
| 23 Total expenses (add lines 14 thru 22) | $817 | $2,471 | $9,321 | | |
| 24 Excess of revenue over expenses (line 13 minus line
23) | $183 | $209 | $359 | | |
