Escolar Documentos
Profissional Documentos
Cultura Documentos
:
o 1120 Warning:
Determine whether the IRS may discuss this return with the
preparer and select appropriate response box.
o 1120 Warning:
o 1120 Warning:
o 1120 Warning:
o 1120 Warning:
o 1120 Warning:
o 1120 Warning:
o 1120 Warning:
o 1120 Error:
o 1120 Warning:
o 1120 Informational:
o 4562 Informational:
o 4626 Informational:
o 4626 Informational:
Expired NOLs may have rolled over from the prior year
return. Please review and adjust the NOL Carryover
worksheet if applicable.
o 1125-E Override:
Form
1120
. . . . . . . . . . By
. . the
. . Numbers,
. . . . . Inc.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1111111
. . . . .
TYPE
Number, street, and room or suite no. If a P.O. box, see instructions.
C Date incorporated
. . . . OR
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Before
. . . .1900,
. . .see
. Options tab.
8/8/2005
. . . . . . . . . . .City
. or
. town
. . . . . . . . . . . . . State
. . . . . . . . . . ZIP
. .code
. . . . . . D
. . Total
. . assets
. . . (see
. . instructions)
.
. . . . . . . . . . Los
. . Angeles
. . . . . . . . . . . . . . CA
. . . . . . . . . . 90012
. . . . . . . . $
. . . . . . . . . .
E Check if:
(1)
Initial return
(2)
Final return
(3)
396,310
Address change
1a
b
c
d
e
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29a
b
c
30
31
32
33
34
35
36
Sign
Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct,
and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
11/29/2012
Signature of officer
Print/Type preparer's name
Paid
Preparer
Use Only
Date
Neda B. Ardekani
Title
Preparer's signature
Date
SELF-PREPARED RETURN
Firm's name
City
PTIN
Firm's EIN
Firm's address
, ending
Name
Income
Phone no.
State
ZIP code
Form
1120 (2011)
Schedule C
11-1111111
(a) Dividends
received
(b) %
Page
see
Dividends on debt-financed stock of domestic and foreign corporations . . . . . . . . . . . . . . . . . . instructions
. . . . . . . . . . . . . 0. . . .
10
. . . . . . . . . . . . . . . . . . . 100
. . . . . . . . . . . . 0. . . .
11
12
13
14
Income from controlled foreign corporations under subpart F (attach Form(s) 5471) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
16
17
Other dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
19
Total dividends. Add lines 1 through 17. Enter here and on page 1, line 4 . . . . . . . . . . . . . . . .0 . . . . . . . . . . . . . . . . . .
20
Total special deductions. Add lines 9, 10, 11, 12, and 18. Enter here and on page 1, line 29b . . . . . . . . . . . . . . . . . . . . . . 0. . . .
Form
1120 (2011)
Schedule J
11-1111111
Page 3
Check if the corporation is a member of a controlled group (attach Schedule O (Form 1120)) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Income tax. Check if a qualified personal service corporation (see instructions) . . . . . .. . .. . . . . . . . .. .. . .. . . X. . . . . .2. . . . . 103,471
. . . . . . . . .
10
11
13
14
15
16
17
18
19
a
b
c
d
20
21
Schedule K
X Cash
Accrual
Yes
Other (specify)
No
541990
actuarial
actuarial
EIN
Name
a Did any foreign or domestic corporation, partnership (including any entity treated as a partnership), trust, or tax-exempt
organization own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all classes of the
corporation's stock entitled to vote? If "Yes," complete Part I of Schedule G (Form 1120) (attach Schedule G) . . . . . . . . . . . . . . . . . X. . . .
b Did any individual or estate own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all
classes of the corporation's stock entitled to vote? If "Yes," complete Part II of Schedule G (Form 1120) (attach Schedule G) . . . . . . . . . X. . . . . .
Form
1120 (2011)
Schedule K
11-1111111
Page 4
No
a Own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all classes of stock entitled to vote of any
foreign or domestic corporation not included onForm 851, Affiliations Schedule? For rules of constructive ownership, see instructions.
If "Yes," complete (i) through (iv) below.
(ii) Employer
Identification Number
(if any)
(iii) Country of
Incorporation
(iv) Percentage
Owned in Voting
Stock
b Own directly an interest of 20% or more, or own, directly or indirectly, an interest of 50% or more in any foreign or domestic partnership
(including an entity treated as a partnership) or in the beneficial interest of a trust? For rules of constructive ownership, see instructions . . . . . . . X. . . .
If "Yes," complete (i) through (iv) below.
(ii) Employer
Identification Number
(if any)
(iv) Maximum
Percentage Owned in
Profit, Loss, or Capital
During this tax year, did the corporation pay dividends (other than stock dividends and distributions in exchange for stock) in
excess of the corporation's current and accumulated earnings and profits? (See sections 301 and 316.) . . . . . . . . . . . . . . . . . . . X
. . . .
If "Yes," file Form 5452, Corporate Report of Nondividend Distributions.
If this is a consolidated return, answer here for the parent corporation and on Form 851 for each subsidiary.
At any time during the tax year, did one foreign person own, directly or indirectly, at least 25%(a)
of the total voting power of all
classes of the corporation's stock entitled to vote or(b) the total value of all classes of the corporation's stock? . . . . . . . . . . . . . . . . . X
. . . .
For rules of attribution, see section 318. If "Yes," enter:
(i) Percentage owned
(c) The corporation may have to fileForm 5472, Information Return of a 25% Foreign-Owned U.S. Corporation or a Foreign
Corporation Engaged in a U.S. Trade or Business. Enter the number of Forms 5472 attached
8
Check this box if the corporation issued publicly offered debt instruments with original issue discount . . . . . . . . . . . . . . . . . . . . . . . . .
If checked, the corporation may have to fileForm 8281, Information Return for Publicly Offered Original Issue Discount Instruments.
Enter the amount of tax-exempt interest received or accrued during the tax year
$
3,000
2
10
Enter the number of shareholders at the end of the tax year (if 100 or fewer)
11
If the corporation has an NOL for the tax year and is electing to forego the carryback period, check here . . . . . . . . . . . . . . . . . . . . . . .
If the corporation is filing a consolidated return, the statement required by Regulations section 1.1502-21(b)(3) must be attached or
the election will not be valid.
12
Enter the available NOL carryover from prior tax years (do not reduce it by any deduction on line 29a.)
13
Are the corporation's total receipts (line 1c plus lines 4 through 10 on page 1) for the tax year
and its total assets at the end of the
tax year less than $250,000? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X. . . .
If "Yes," the corporation is not required to complete Schedules L, M-1, and M-2 on page 5. Instead, enter the total amount of cash
distributions and the book value of property distributions (other than cash) made during the tax year.
$
14
Is the corporation required to file Schedule UTP (Form 1120), Uncertain Tax Position Statement (see instructions)? . . . . . . . . . . . . . . . . . . .
If "Yes," complete and attach Schedule UTP.
15a Did the corporation make any payments in 2011 that would require it to file Form(s) 1099 (see instructions)? . . . . . . . . . . . . . . . . . .X . . . .
b If "Yes," did or will the corporation file all required Forms 1099? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Form
1120 (2011)
Schedule L
11-1111111
Beginning of tax year
(a)
(b)
Page 5
(d)
1
2a
b
3
4
5
6
7
8
9
10a
b
11a
b
12
13a
b
14
15
Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23,220
. . . . . . . . . . . . . . . . . . 26,300
. . . . . . .
Trade notes and accounts receivable . . . . . . . . . . . . . .35,850
. . . . . . . . . . . . . . . . . .32,100
. . . . . . . . . . . . . . . .
Less allowance for bad debts . . . . . . . . . . . . (. . . . . . . .) . . . . . . 35,850
. . . . (. . . . . . . .) . . . . . . 32,100
. . . . . . .
Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
U.S. government obligations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax-exempt securities (see instructions) . . . . . . . . . . . . . . . . . . . . . .75,000
. . . . . . . . . . . . . . . . . .75,000
. . . . . . .
Other current assets (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Loans to shareholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mortgage and real estate loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other investments (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Buildings and other depreciable assets . . . . . . . . . . . . 295,600
. . . . . . . . . . . . . . . . . . 311,700
. . . . . . . . . . . . . . . . . .
Less accumulated depreciation . . . . . . . . . . . .( . . . . 63,500)
. . . . . . . . 232,100
. . . . . (. . . . . 85,900)
. . . . . . . . .225,800
. . . . . . . .
Depletable assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Less accumulated depletion . . . . . . . . . . . . .( . . . . . . . ). . . . . . . . . 0 . .( . . . . . . . ). . . . . . . . . 0. . . . .
Land (net of any amortization) . . . . . . . . . . . . . . . . . . . . . . . . . 35,000
. . . . . . . . . . . . . . . . . . .35,000
. . . . . . .
Intangible assets (amortizable only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Less accumulated amortization . . . . . . . . . . . (. . . . . . . . ) . . . . . . . . .0 . (. . . . . . . . ) . . . . . . . . .0 . . . . .
Other assets (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . .2,980
. . . . . . . . . . . . . . . . . . 2,110
. . . . . . .
Total assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404,150
. . . . . . . . . . . . . . . . . . 396,310
. . . . . . . .
16
17
18
19
20
21
22
23
24
25
26
27
28
Schedule M-1
0
3,800 9 Add lines 7 and 8 . . . . . . . . . . . . . . . . .3,000
. . . . . .
Add lines 1 through 5 . . . . . . . . . . . . . . . . . . 298,630
. . . . 10
. . Income
. . . (page
. . . 1,. line
. .28)line
. . . 6
. less
. . line
. .9 . . . . . 295,630
. . . . . . . .
Schedule M-2
1
2
3
1120 (2011)
Form
4626
Name
4
a
b
c
d
5
6
7
Alternative minimum taxable income. Subtract line 6 from line 5. If the corporation held a residual
interest in a REMIC, see instructions . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. .. .. .. 7. . . . . . . . 297,880
.. .. .. .. .. .. ..
8
a
Exemption phase-out (if line 7 is $310,000 or more, skip lines 8a and 8b and enter -0- on line 8c):
Subtract $150,000 from line 7 (if completing this line for a member of a
controlled group, see instructions). If zero or less, enter -0- . . . . . . . . . . 8a
. . . . . 147,880
. . . . . . . . . . . . . . .
Multiply line 8a by 25% (.25) . . . . . . . . . . . . . . . . . . . . . . 8b
. . . . . .36,970
. . . . . . . . . . . . . .
Exemption. Subtract line 8b from $40,000 (if completing this line for a member of a controlled group,
see instructions). If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . 8c
. . . . . .3,030
. . . . .
Subtract line 8c from line 7. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . 9. . . . .294,850
. . . . . .
Multiply line 9 by 20% (.20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10. . . . .58,970
. . . . . .
Alternative minimum tax foreign tax credit (AMTFTC) (see instructions) . . . . . . . . . . . . . . 11
. . . . . . . . . . . .
Tentative minimum tax. Subtract line 11 from line 10 . . . . . . . . . . . . . . .. .. .. .. .. .. .. ..12. . . . . . . . .58,970
.. .. .. .. .. ..
Regular tax liability before applying all credits except the foreign tax credit . . . . . . . . . . . . . .13. . . . 103,471
. . . . . . .
Alternative minimum tax. Subtract line 13 from line 12. If zero or less, enter -0-. Enter here and on
Form 1120, Schedule J, line 3, or the appropriate line of the corporation's income tax return . . . . . . 14
. . . . . . . 0. . . .
b
c
9
10
11
12
13
14
Form
4626 (2011)
SCHEDULE G
(Form 1120)
Name
Part I
11-1111111
Certain Entities Owning the Corporation's Voting Stock. (Form 1120, Schedule K, Question 4a).
Complete columns (i) through (v) below for any foreign or domestic corporation, partnership (including
any entity treated as a partnership), trust, or tax-exempt organization that owns directly 20% or more, or
owns, directly or indirectly, 50% or more of the total voting power of all classes of the corporation's
stock entitled to vote (see instructions).
(i) Name of Entity
Part II
OMB No.1545-0123
Certain Individuals and Estates Owning the Corporation's Voting Stock. (Form 1120, Schedule K,
Question 4b). Complete columns (i) through (iv) below for any individual or estate that owns directly 20%
or more, or owns, directly or indirectly, 50% or more of the total voting power of all classes of the
corporation's stock entitled to vote (see instructions).
(i) Name of Individual or Estate
(ii) Identifying
Number (if any)
(iii) Country of
Citizenship (see
instructions)
Belinda Jackson
123-45-6789
United States
50.000%
Ahmad Sharma
987-65-4321
United States
50.000%
SCHEDULE PH
(Form 1120)
Name
Part I
Taxable income before net operating loss deduction and special deductions. Enter
amount from Form 1120, line 28 . . . . . . . . . . . . . . . . . . . . . . . . . 1. . . . . . . 295,630
. . . . . . .
2
Contributions deducted in figuring line 1. Enter amount from Form 1120, line 19 . . . . . . 2
. . . . . . . . . 1,000
. . . . .
3
Excess expenses and depreciation under section 545(b)(6). Enter amount from Part V,
line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 . . . . . . . . . . . . . .
4
Total. Add lines 1 through 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. . . . . . . 296,630
. . . . . . .
5
Federal and foreign income, war profits, and excess profits taxes not deducted in figuring
line 1 (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 . . . . . . . . . . . . . .
6
Contributions deductible under section 545(b)(2). See instructions for limitation . . . . . . .6 . . . . . . . . . . . . . .
7
Net operating loss for the preceding tax year deductible under section 545(b)(4) . . . . . . 7. . . . . . . . . . . . . .
8 a Net capital gain from Schedule D (Form 1120), line 13 . . . . .8a. . . . . . . . . . . . . . . . . . . . . . . . .
b Less: Income tax on this net capital gain (see section
545(b)(5)) (attach computation) . . . . . . . . . . . . . .8b. . . . . . . . 4,925
. . . 8c
. . . . . . . . .-4,925
. . . . . .
9
Deduction for dividends paid (other than dividends paid after the end of the tax year).
Enter amount from Part VI, line 5 . . . . . . . . . . . . . . . . . . . . . . . . . 9 . . . . . . . . . . . . . .
Additions
Deductions
11-1111111
10
11
12
13
Note: If the information in Part II and Part IV is not submitted with the return, the limitation period for assessment and
collection of the PHC tax is any time within 6 years after the return is filed. See section 6501(f).
Part II
14
15 a
b
16
17
18 a
b
19 a
b
20
21
22
23
24
25
Part III
26
PHC tax. Multiply the amount on line 13 by the tax rate for undistributed PHC income (see
instructions). Enter the result here and on Schedule J, line 8, or on the proper line of the
appropriate tax return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
. . . . . . . . . . 0
. . . .
For Paperwork Reduction Act Notice, see the Instructions for Form 1120.
(HTA)
Part IV
11-1111111
Page
(b) Address
(c) Preferred
(d) Common
St
Zip
St
Zip
St
Zip
St
Zip
St
Zip
Add the amounts in columns (c) and (d) and enter the totals here . . . . . . . . . . . . . . . . . .% . . . . . %
. . . . .
Part V
Excess of Expenses and Depreciation Over Income From Property Not Allowable
Under Section 545(b)(6) (see instructions for Part I, line 3)
(a) Description of
property
(b) Date
acquired
(c) Cost or
other basis
(d) Depreciation
deduction
(e) Repairs,
insurance, and
other expenses
(section 162)
(attach schedule)
(f) Total of
columns (d)
and (e)
(h) Excess
(col. (f) less
col. (g))
Total excess of expenses and depreciation over rent or other compensation. Add the amounts in column
(h). Enter the total here and on Part I, line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. . . .
Note: Attach a statement showing the names and addresses of persons from whom rent or other
compensation was received for the use of, or the right to use, each property.
Part VI
Taxable dividends paid. Do not include dividends considered as paid in the preceding tax
year under section 563 or deficiency dividends as defined in section 547 . . . . . . . . . . . 1 . . . . . . . . . . . . . .
Dividend carryover from first and second preceding tax years. Attach computation . . . . . . . 4. . . . . . . . . . . . . .
Deduction for dividends paid. Add lines 3 and 4. Enter the total here and on Part I,
line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. . . . . . . . . . 0. . . . .
Schedule PH (Form 1120) (Rev. 12-2011)
Form
1125-E
(December 2011)
Department of the Treasury
Internal Revenue Service
Compensation of Officers
OMB No. 1545-2225
Name
11-1111111
Note. Complete Form 1125-E only if total receipts are $500,000 or more. See instructions for definition of total receipts.
(a) Name of officer
Belinda Jackson
Ahmad Sharma
(c) Percent of
time devoted to
business
(e) Preferred
(f) Amount of
compensation
123-45-6789
50.00%
50.00%
125,000
987-65-4321
50.00%
50.00%
125,000
Subtract line 3 from line 2. Enter the result here and on Form 1120, page 1, line 12 or the
appropriate line of your tax return . . . . . . . . . . . . . . . . . . . . . . . . . . .4 . . . . . . . . .0 . . . .
11-1111111
1 Dividends paid in cash on stock held by an employee stock ownership plan (see instructions) . . . . . 1. . . . . 20,000
. . . . . . . .
2 Travel, Meals and Entertainment
a Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
. . . . . .6,300
. . . . . . .
b Meals and entertainment, subject to 50% limit . . . . . . . . . . . . . . .2b. . . . . 7,600
. . . . . . . . . . . . . . .
c Meals and entertainment, subject to 80% limit (DOT) . . . . . . . . . . . . 2c. . . . . . . . . . . . . . . . . . . . .
d Less disallowed . . . . . . . . . . . . . . . . . . . . . . . . . . 2d
. . . . . .3,800
. . . . . . . . . . . . . . .
e Subtract line d from lines b and c . . . . . . . . . . . . . . . . . . . . . . . . . . . .2e. . . . . 3,800
. . . . . . .
3 Dues and subscriptions
3
4,900
4 Insurance
4
15,000
5 Legal and professional fees
5
12,500
6 Miscellaneous
6
3,000
7 Telephone
7
2,400
8 Total other deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 . . . . 67,900
. . . . . . . .
9 Total deductions less expenses for offsetting credits . . . . . . . . . . . . . . . . . . . . . . 9 . . . . .67,900
. . . . . . .
Beginning
End
1 Other Assets
1
2,980
2,110
2 Total other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. . . . . 2,980
. . . . . . . . .2,110
. . . . . . .
11-1111111
1 Salaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. . . . . 5,000
. . . . . . . . . . . . . . . .
2 Wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 . . . . . . . . . . . . . . . . . . . .
3
3
4 Total salaries and wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 . . . . .5,000
. . . . . . .
Salaries and wages reported elsewhere on return:
5 Amounts included in Cost of Goods Sold . . . . . . . . . . . . . . . . . . .5 . . . . . . .0 . . . . . . . . . . . . .
6 Elective contributions to a section 401(k) cash or deferred
arrangement, or amounts contributed under a salary reductions SEP
agreement or a SIMPLE IRA plan . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . . . . . . . . . . . . . . .
7 Total salaries and wages reported elsewhere on return . . . . . . . . . . . . . . . . . . . . . 7. . . . . . . 0. . . . . .
Less employment credits:
8 From Form 5884 - Work Opportunity Credit . . . . . . . . . . . . . . . . . 8. . . . . . . 0. . . . . . . . . . . . . .
9 From Form 8844 - Empowerment Zone Employment Credit . . . . . . . . . . . 9 . . . . . . . 0 . . . . . . . . . . . . .
10 From Form 8845 - Indian Employment Credit . . . . . . . . . . . . . . . . 10
. . . . . . . 0. . . . . . . . . . . . . .
11
11
12
12
13 Total employment credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
. . . . . . . 0. . . . . .
14 Reduction of expenses for other offsetting credits (see attached statement) . . . . . . . . . . . . .14. . . . . . .0 . . . . .
15 Total salaries and wages less employment credits and expense reductions . . . . . . . . . . . . . 15. . . . . 5,000
. . . . . . .
11-1111111
Amount
1
a
b
2
a
b
c
d
e
3
4
5
(B)
Adjustment
under Section
170(d)(2)(B)
(C)
Deduction
Allowed in
Current Year
(D)
Contribution
Carryover
. . . . . . 17
. . . . . . . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
. .
. 0.
. .
. .
. .
. .
.
.
.
.
.
.
. .
. 18
.
.19.
.20.
.21.
.22.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. .
. 0.
. 0.
.0 .
.0 .
.0 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. .
. .
.
.
.
.
Part I - Contribution carryover, NOL carryover, and Taxable income without contribution deduction
1 2011 taxable income without contributions deduction . . . . . . . . . . . . . . . . . . . . . . 1. . . . 319,030
. . . . . . . .
2 Contribution deduction available in 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. . . . . 1,000
. . . . . . .
3 Prior year NOL carryover to 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 . . . . . . .0 . . . . .
Part III - Determination of 2011 contribution carryover to next year under Section 170(d)(2)(B)
1
2
3
4
5
11-1111111
No
X Is this tax year the corporation's first year in existence?
If "Yes", Stop here.
The corporation is exempt from AMT with no other qualification requirements.
X Did the corporation lose small corporation status in a prior year? If so, enter the change date:
If "Yes", Stop here.
Once a corporation loses its small corporation status, it cannot qualify in any subsequent tax year.
Tax Year
2005
2006
2007
2008
2009
2010
2011
Yes
or
N/A
X
Annualized
Gross Receipts
530,000
Prior Three
Year Average
0
0
0
0
0
0
0
No
Did the corporation have average annual gross receipts of $5 million or less for the FIRST
three-year period beginning after 1993 (for calendar year corps in existence on 1/1/1994
through 1996)?
Were the corporation's average gross receipts for EVERY three-year period beginning after
1994 and ending before its tax year beginning in 2011 $7.5 million or less? (For calendar
year corporations in existence on 1/1/1994, the three year periods are: 1995-1997, 1996-1998,
1997-1999, 1998-2000, 1999-2001, 2000-2002, 2001-2003, 2002-2004, 2003-2005, 2004-2006, 2005-2007,
2006-2008, 2007-2009, 2008-2010).
If the corporation had only one prior tax year, were the gross receipts for the prior tax
year $5 million or less, (or the corporation was established before 1994)?
Corporation qualifies as a small corporation or is otherwise exempt from the alternative minimum tax.
11-1111111
Assets
Beginning
Ending
Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 . . . . 23,220
. . . . . . . . 26,300
. . . . . . . .
Trade notes and accounts receivable . . . . . . . . . . . . . . . . . . .2a. . . . .35,850
. . . . . . . .32,100
. . . . . . .
Less allowance for bad debts . . . . . . . . . . . . . . . . . . . . . .2b. . . . . . . . . . . . . . . . . . . . .
Net trade notes and accounts receivable . . . . . . . . . . . . . . . . . . 2c. . . . .35,850
. . . . . . . . 32,100
. . . . . . . .
Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. . . . . . . 0. . . . . . . . 0. . . . . .
U.S. government obligations . . . . . . . . . . . . . . . . . . . . . . 4. . . . . . . . . . . . . . . . . . . . .
Tax-exempt securities . . . . . . . . . . . . . . . . . . . . . . . . . 5 . . . . .75,000
. . . . . . . .75,000
. . . . . . .
Other current assets . . . . . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . 0
. . . . . . . . 0
. . . . . .
Loans to shareholders . . . . . . . . . . . . . . . . . . . . . . . . . 7. . . . . . . . . . . . . . . . . . . . .
Mortgage and real estate loans . . . . . . . . . . . . . . . . . . . . . 8. . . . . . . . . . . . . . . . . . . . .
Other investments . . . . . . . . . . . . . . . . . . . . . . . . . . 9. . . . . . . 0. . . . . . . . 0. . . . . .
Buildings and other depreciable assets . . . . . . . . . . . . . . . . . .10a
. . . . 295,600
. . . . . . . . 311,700
. . . . . . . . .
Less accumulated depreciation . . . . . . . . . . . . . . . . . . . . .10b
. . . . .-63,500
. . . . . . . .-85,900
. . . . . . . .
Net buildings and other depreciable assets . . . . . . . . . . . . . . . . 10c
. . . . . 232,100
. . . . . . . . 225,800
. . . . . . . .
Depletable assets . . . . . . . . . . . . . . . . . . . . . . . . . . 11a
. . . . . . . . . . . . . . . . . . . . .
Less accumulated depletion . . . . . . . . . . . . . . . . . . . . . . 11b
. . . . . . . . . . . . . . . . . . . . .
Net depletable assets . . . . . . . . . . . . . . . . . . . . . . . . .11c
. . . . . . . 0 . . . . . . . . 0. . . . . .
Land (net of any amortization) . . . . . . . . . . . . . . . . . . . . . 12
. . . . . 35,000
. . . . . . . . 35,000
. . . . . . . .
Intangible assets (amortizable only) . . . . . . . . . . . . . . . . . . . 13a
. . . . . . . 0
. . . . . . . . 0
. . . . . .
Less accumulated amortization . . . . . . . . . . . . . . . . . . . . .13b
. . . . . . . 0. . . . . . . . 0. . . . . .
Net intangible assets . . . . . . . . . . . . . . . . . . . . . . . . . 13c
. . . . . . . 0. . . . . . . . 0. . . . . .
Other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
. . . . . .2,980
. . . . . . . . 2,110
. . . . . . .
Total assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15. . . . 404,150
. . . . . . . . 396,310
. . . . . . . .
16
17
18
19
20
21
22a
22b
22c
23
24
25
26
27
28
Accounts payable . . . . . . . . . . . . . . . . . . . . . . . . . . 16
. . . . . 34,800
. . . . . . . . 35,596
. . . . . . . .
Mortgages, notes, bonds payable in less than 1 year . . . . . . . . . . . . . 17
. . . . . . . . . . . . . . . . . . . . .
Other current liabilities . . . . . . . . . . . . . . . . . . . . . . . . 18
. . . . . . 9,350
. . . . . . . 18,250
. . . . . . . .
Loans from shareholders . . . . . . . . . . . . . . . . . . . . . . . 19
. . . . . . . . . . . . . . . . . . . . .
Mortgages, notes, bonds payable in 1 year or more . . . . . . . . . . . . . .20. . . . 114,000
. . . . . . . . 108,600
. . . . . . . .
Other liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . .21. . . . . . .0 . . . . . . . .0 . . . . .
Capital stock (preferred) . . . . . . . . . . . . . . . . . . . . . . . .22a
. . . . . . . . . . . . . . . . . . . . .
Capital stock (common) . . . . . . . . . . . . . . . . . . . . . . . .22b
. . . . 200,000
. . . . . . . . 200,000
. . . . . . . . .
Net Capital Stock . . . . . . . . . . . . . . . . . . . . . . . . . . .22c
. . . . 200,000
. . . . . . . . 200,000
. . . . . . . . .
Additional paid-in capital . . . . . . . . . . . . . . . . . . . . . . . .23. . . . . . . . . . . . . . . . . . . .
Retained earnings - appropriated . . . . . . . . . . . . . . . . . . . . 24
. . . . . . . 0
. . . . . . . . 0
. . . . . .
Retained earnings - unappropriated . . . . . . . . . . . . . . . . . . . 25
. . . . . 46,000
. . . . . . . . 33,864
. . . . . . . .
Adjustments to shareholders' equity . . . . . . . . . . . . . . . . . . . 26
. . . . . . . 0. . . . . . . . 0. . . . . .
Less cost of treasury stock . . . . . . . . . . . . . . . . . . . . . . . 27. . . . . . . . . . . . . . . . . . . . .
Total liabilities and shareholders' equity . . . . . . . . . . . . . . . . . .28. . . . 404,150
. . . . . . . . 396,310
. . . . . . . . .
11-1111111
c
3
a
b
c
d
e
f
4
a
b
c
d
e
f
5
a
b
c
d
e
f
6
7
8
9
10
Pre-adjustment AMTI. Enter the amount from line 3 of Form 4626 . . . . . . . . . . . . . . . . 1. . . . 295,630
. . . . . . . . .
ACE depreciation adjustment:
AMT depreciation . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
. . . . . . . 0. . . . . . . . . . . . . .
ACE depreciation:
(1) Post-1993 property . . . . . . . . . . . . . . . . 2b1
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Post-1989, pre-1994 property . . . . . . . . . . . . 2b2
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Pre-1990 MACRS property . . . . . . . . . . . . . 2b3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) Pre-1990 original ACRS property . . . . . . . . . . . 2b4
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(5) Property described in sections 168(f)(1)
through (4) . . . . . . . . . . . . . . . . . . . .2b5
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(6) Other property . . . . . . . . . . . . . . . . . . 2b6
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(7) Total ACE depreciation. Add lines 2b(1) through 2b(6) . . . . . . . . . . .2b7
. . . . . . . 0. . . . . . . . . . . . . .
ACE depreciation adjustment. Subtract line 2b(7) from line 2a . . . . . . . . . . . . . . . . . .2c. . . . . . .0 . . . . .
Inclusion in ACE of items included in earnings and profits (E&P):
Tax-exempt interest income . . . . . . . . . . . . . . . . . . . . . . . 3a
. . . . . 3,000
. . . . . . . . . . . . . . . .
Death benefits from life insurance contracts . . . . . . . . . . . . . . . . . 3b. . . . . . . . . . . . . . . . . . . . .
All other distributions from life insurance contracts (including surrenders) . . . . . 3c
. . . . . . . . . . . . . . . . . . . . .
Inside buildup of undistributed income in life insurance contracts . . . . . . . . .3d. . . . . . . . . . . . . . . . . . . .
Other items (see Regulations sections 1.56(g)-1(c)(6)(iii) through (ix) for a
partial list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3e
. . . . . . . . . . . . . . . . . . . . .
Total increase to ACE from inclusion in ACE of items included in E&P. Add lines 3a through 3e . . . . .3f . . . . . 3,000
. . . . . . .
Disallowance of items not deductible from E&P:
Certain dividends received . . . . . . . . . . . . . . . . . . . . . . . .4a. . . . . . . . . . . . . . . . . . . .
Dividends paid on certain preferred stock of public utilities that are deductible
under section 247 . . . . . . . . . . . . . . . . . . . . . . . . . . . 4b
. . . . . . . . . . . . . . . . . . . . .
Dividends paid to an ESOP that are deductible under section 404(k) . . . . . . . 4c
. . . . . . . . . . . . . . . . . . . . .
Nonpatronage dividends that are paid and deductible under section
1382(c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4d
. . . . . . . . . . . . . . . . . . . . .
Other items (see Regulations sections 1.56(g)-1(d)(3)(i) and (ii) for a
partial list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4e
. . . . . . . . . . . . . . . . . . . . .
Total increase to ACE because of disallowance of items not deductible from E&P.
Add lines 4a through 4e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4f. . . . . . . 0 . . . . .
Other adjustments based on rules for figuring E&P:
Intangible drilling costs . . . . . . . . . . . . . . . . . . . . . . . . . 5a
. . . . . . . . . . . . . . . . . . . . .
Circulation expenditures . . . . . . . . . . . . . . . . . . . . . . . . 5b
. . . . . . . . . . . . . . . . . . . . .
Organizational expenditures . . . . . . . . . . . . . . . . . . . . . . . 5c. . . . . . . . . . . . . . . . . . . . .
LIFO inventory adjustments . . . . . . . . . . . . . . . . . . . . . . . 5d
. . . . . . . . . . . . . . . . . . . . .
Installments sales . . . . . . . . . . . . . . . . . . . . . . . . . . . 5e
. . . . . . . . . . . . . . . . . . . . .
Total other E&P adjustments. Combine lines 5a through 5e . . . . . . . . . . . . . . . . . . .5f . . . . . . .0 . . . . .
Disallowance of loss on exchange of debt pools . . . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . . . . . . .
Acquisition expenses of life insurance companies for qualified foreign contracts . . . . . . . . . . . 7. . . . . . . . . . . .
Depletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 . . . . . . . . . . . .
Basis adjustments in determining gain or loss from sale or exchange of pre-1994 property . . . . . . . 9 . . . . . . . . . . . .
Adjusted current earnings. Combine lines 1, 2c, 3f, 4f, and 5f through 9. Enter the result here
and on line 4a of Form 4626 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
. . . . 298,630
. . . . . . . . .
Form
1120
33
34
35
36
Sign
Here
. . . . . . . . . . By
. . the
. . Numbers,
. . . . . Inc.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1111111
. . . . .
TYPE
Number, street, and room or suite no. If a P.O. box, see instructions.
C Date incorporated
. . . . OR
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Before
. . . .1900,
. . .see
. Options tab.
. . . . . . . . . . Los
. . Angeles
. . . . . . . . . . . . . . CA
. . . . . . . . . . 90012
. . . . . . . . $
. . . . . . . . . .
E Check if:
(1)
Initial return
(2)
Final return
(3)
396,310
Address change
CO
PY
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct,
and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
11/29/2012
Signature of officer
Print/Type preparer's name
Paid
Preparer
Use Only
Date
Neda B. Ardekani
Title
Preparer's signature
Date
SELF-PREPARED RETURN
Firm's name
City
PTIN
Firm's EIN
Firm's address
8/8/2005
. . . . . . . . . . .City
. or
. town
. . . . . . . . . . . . . State
. . . . . . . . . . ZIP
. .code
. . . . . . D
. . Total
. . assets
. . . (see
. . instructions)
.
CL
IE
NT
1a
b
c
d
e
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29a
b
c
30
31
32
, ending
Name
Income
Phone no.
State
ZIP code
Form
1120 (2011)
Schedule C
11-1111111
(a) Dividends
received
(b) %
Page
see
Dividends on debt-financed stock of domestic and foreign corporations . . . . . . . . . . . . . . . . . . instructions
. . . . . . . . . . . . . 0. . . .
10
T
N
E
I
L
C
O
C
Y
P
. . . . . . . . . . . . . . . . . . . 100
. . . . . . . . . . . . 0. . . .
11
12
13
14
Income from controlled foreign corporations under subpart F (attach Form(s) 5471) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
16
17
Other dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
19
Total dividends. Add lines 1 through 17. Enter here and on page 1, line 4 . . . . . . . . . . . . . . . .0 . . . . . . . . . . . . . . . . . .
20
Total special deductions. Add lines 9, 10, 11, 12, and 18. Enter here and on page 1, line 29b . . . . . . . . . . . . . . . . . . . . . . 0. . . .
Form
1120 (2011)
Schedule J
11-1111111
Page 3
Check if the corporation is a member of a controlled group (attach Schedule O (Form 1120)) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Income tax. Check if a qualified personal service corporation (see instructions) . . . . . .. . .. . . . . . . . .. .. . .. . . X. . . . . .2. . . . . 103,471
. . . . . . . . .
CO
PY
10
11
13
14
15
16
17
18
a
b
c
d
20
21
CL
I
19
EN
T
12
Schedule K
X Cash
Accrual
Yes
Other (specify)
No
541990
actuarial
actuarial
c Product or service
3
EIN
Name
a Did any foreign or domestic corporation, partnership (including any entity treated as a partnership), trust, or tax-exempt
organization own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all classes of the
corporation's stock entitled to vote? If "Yes," complete Part I of Schedule G (Form 1120) (attach Schedule G) . . . . . . . . . . . . . . . . . X. . . .
b Did any individual or estate own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all
classes of the corporation's stock entitled to vote? If "Yes," complete Part II of Schedule G (Form 1120) (attach Schedule G) . . . . . . . . . X. . . . . .
Form
1120 (2011)
Schedule K
11-1111111
Page 4
No
a Own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all classes of stock entitled to vote of any
foreign or domestic corporation not included onForm 851, Affiliations Schedule? For rules of constructive ownership, see instructions.
If "Yes," complete (i) through (iv) below.
(ii) Employer
Identification Number
(if any)
(iii) Country of
Incorporation
CO
PY
(iv) Percentage
Owned in Voting
Stock
b Own directly an interest of 20% or more, or own, directly or indirectly, an interest of 50% or more in any foreign or domestic partnership
(including an entity treated as a partnership) or in the beneficial interest of a trust? For rules of constructive ownership, see instructions . . . . . . . X. . . .
If "Yes," complete (i) through (iv) below.
(ii) Employer
Identification Number
(if any)
CL
IE
NT
(iv) Maximum
Percentage Owned in
Profit, Loss, or Capital
During this tax year, did the corporation pay dividends (other than stock dividends and distributions in exchange for stock) in
excess of the corporation's current and accumulated earnings and profits? (See sections 301 and 316.) . . . . . . . . . . . . . . . . . . . X
. . . .
If "Yes," file Form 5452, Corporate Report of Nondividend Distributions.
If this is a consolidated return, answer here for the parent corporation and on Form 851 for each subsidiary.
At any time during the tax year, did one foreign person own, directly or indirectly, at least 25%(a)
of the total voting power of all
classes of the corporation's stock entitled to vote or(b) the total value of all classes of the corporation's stock? . . . . . . . . . . . . . . . . . X
. . . .
For rules of attribution, see section 318. If "Yes," enter:
(i) Percentage owned
(c) The corporation may have to fileForm 5472, Information Return of a 25% Foreign-Owned U.S. Corporation or a Foreign
Corporation Engaged in a U.S. Trade or Business. Enter the number of Forms 5472 attached
8
Check this box if the corporation issued publicly offered debt instruments with original issue discount . . . . . . . . . . . . . . . . . . . . . . . . .
If checked, the corporation may have to fileForm 8281, Information Return for Publicly Offered Original Issue Discount Instruments.
Enter the amount of tax-exempt interest received or accrued during the tax year
$
3,000
2
10
Enter the number of shareholders at the end of the tax year (if 100 or fewer)
11
If the corporation has an NOL for the tax year and is electing to forego the carryback period, check here . . . . . . . . . . . . . . . . . . . . . . .
If the corporation is filing a consolidated return, the statement required by Regulations section 1.1502-21(b)(3) must be attached or
the election will not be valid.
12
Enter the available NOL carryover from prior tax years (do not reduce it by any deduction on line 29a.)
13
Are the corporation's total receipts (line 1c plus lines 4 through 10 on page 1) for the tax year
and its total assets at the end of the
tax year less than $250,000? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X. . . .
If "Yes," the corporation is not required to complete Schedules L, M-1, and M-2 on page 5. Instead, enter the total amount of cash
distributions and the book value of property distributions (other than cash) made during the tax year.
$
14
Is the corporation required to file Schedule UTP (Form 1120), Uncertain Tax Position Statement (see instructions)? . . . . . . . . . . . . . . . . . . .
If "Yes," complete and attach Schedule UTP.
15a Did the corporation make any payments in 2011 that would require it to file Form(s) 1099 (see instructions)? . . . . . . . . . . . . . . . . . .X . . . .
b If "Yes," did or will the corporation file all required Forms 1099? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Form
1120 (2011)
Schedule L
11-1111111
Beginning of tax year
(a)
(b)
Page 5
(d)
Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23,220
. . . . . . . . . . . . . . . . . . 26,300
. . . . . . .
Trade notes and accounts receivable . . . . . . . . . . . . . .35,850
. . . . . . . . . . . . . . . . . .32,100
. . . . . . . . . . . . . . . .
Less allowance for bad debts . . . . . . . . . . . . (. . . . . . . .) . . . . . . 35,850
. . . . (. . . . . . . .) . . . . . . 32,100
. . . . . . .
Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
U.S. government obligations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax-exempt securities (see instructions) . . . . . . . . . . . . . . . . . . . . . .75,000
. . . . . . . . . . . . . . . . . .75,000
. . . . . . .
Other current assets (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Loans to shareholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mortgage and real estate loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other investments (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Buildings and other depreciable assets . . . . . . . . . . . . 295,600
. . . . . . . . . . . . . . . . . . 311,700
. . . . . . . . . . . . . . . . . .
Less accumulated depreciation . . . . . . . . . . . .( . . . . 63,500)
. . . . . . . . 232,100
. . . . . (. . . . . 85,900)
. . . . . . . . .225,800
. . . . . . . .
Depletable assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Less accumulated depletion . . . . . . . . . . . . .( . . . . . . . ). . . . . . . . . 0 . .( . . . . . . . ). . . . . . . . . 0. . . . .
Land (net of any amortization) . . . . . . . . . . . . . . . . . . . . . . . . . 35,000
. . . . . . . . . . . . . . . . . . .35,000
. . . . . . .
Intangible assets (amortizable only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Less accumulated amortization . . . . . . . . . . . (. . . . . . . . ) . . . . . . . . .0 . (. . . . . . . . ) . . . . . . . . .0 . . . . .
Other assets (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . .2,980
. . . . . . . . . . . . . . . . . . 2,110
. . . . . . .
Total assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404,150
. . . . . . . . . . . . . . . . . . 396,310
. . . . . . . .
16
17
18
19
20
21
22
23
24
25
26
27
28
Schedule M-1
EN
T
CO
PY
1
2a
b
3
4
5
6
7
8
9
10a
b
11a
b
12
13a
b
14
15
CL
I
1
2
3
4
0
3,800 9 Add lines 7 and 8 . . . . . . . . . . . . . . . . .3,000
. . . . . .
Add lines 1 through 5 . . . . . . . . . . . . . . . . . . 298,630
. . . . 10
. . Income
. . . (page
. . . 1,. line
. .28)line
. . . 6
. less
. . line
. .9 . . . . . 295,630
. . . . . . . .
Schedule M-2
1
2
3
1120 (2011)
Form
4626
Name
4
a
b
5
6
CL
IE
NT
c
d
CO
PY
2
a
b
c
d
e
f
g
h
i
j
k
l
m
n
o
3
Alternative minimum taxable income. Subtract line 6 from line 5. If the corporation held a residual
interest in a REMIC, see instructions . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. .. .. .. 7. . . . . . . . 297,880
.. .. .. .. .. .. ..
8
a
Exemption phase-out (if line 7 is $310,000 or more, skip lines 8a and 8b and enter -0- on line 8c):
Subtract $150,000 from line 7 (if completing this line for a member of a
controlled group, see instructions). If zero or less, enter -0- . . . . . . . . . . 8a
. . . . . 147,880
. . . . . . . . . . . . . . .
Multiply line 8a by 25% (.25) . . . . . . . . . . . . . . . . . . . . . . 8b
. . . . . .36,970
. . . . . . . . . . . . . .
Exemption. Subtract line 8b from $40,000 (if completing this line for a member of a controlled group,
see instructions). If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . 8c
. . . . . .3,030
. . . . .
Subtract line 8c from line 7. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . 9. . . . .294,850
. . . . . .
Multiply line 9 by 20% (.20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10. . . . .58,970
. . . . . .
Alternative minimum tax foreign tax credit (AMTFTC) (see instructions) . . . . . . . . . . . . . . 11
. . . . . . . . . . . .
Tentative minimum tax. Subtract line 11 from line 10 . . . . . . . . . . . . . . .. .. .. .. .. .. .. ..12. . . . . . . . .58,970
.. .. .. .. .. ..
Regular tax liability before applying all credits except the foreign tax credit . . . . . . . . . . . . . .13. . . . 103,471
. . . . . . .
Alternative minimum tax. Subtract line 13 from line 12. If zero or less, enter -0-. Enter here and on
Form 1120, Schedule J, line 3, or the appropriate line of the corporation's income tax return . . . . . . 14
. . . . . . . 0. . . .
b
c
9
10
11
12
13
14
Form
4626 (2011)
SCHEDULE G
(Form 1120)
Name
CL
IE
NT
Part II
11-1111111
Certain Entities Owning the Corporation's Voting Stock. (Form 1120, Schedule K, Question 4a).
Complete columns (i) through (v) below for any foreign or domestic corporation, partnership (including
any entity treated as a partnership), trust, or tax-exempt organization that owns directly 20% or more, or
owns, directly or indirectly, 50% or more of the total voting power of all classes of the corporation's
stock entitled to vote (see instructions).
CO
PY
Part I
OMB No.1545-0123
Certain Individuals and Estates Owning the Corporation's Voting Stock. (Form 1120, Schedule K,
Question 4b). Complete columns (i) through (iv) below for any individual or estate that owns directly 20%
or more, or owns, directly or indirectly, 50% or more of the total voting power of all classes of the
corporation's stock entitled to vote (see instructions).
(i) Name of Individual or Estate
(ii) Identifying
Number (if any)
(iii) Country of
Citizenship (see
instructions)
Belinda Jackson
123-45-6789
United States
50.000%
Ahmad Sharma
987-65-4321
United States
50.000%
SCHEDULE PH
(Form 1120)
Name
Part I
Taxable income before net operating loss deduction and special deductions. Enter
amount from Form 1120, line 28 . . . . . . . . . . . . . . . . . . . . . . . . . 1. . . . . . . 295,630
. . . . . . .
2
Contributions deducted in figuring line 1. Enter amount from Form 1120, line 19 . . . . . . 2
. . . . . . . . . 1,000
. . . . .
3
Excess expenses and depreciation under section 545(b)(6). Enter amount from Part V,
line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 . . . . . . . . . . . . . .
4
Total. Add lines 1 through 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. . . . . . . 296,630
. . . . . . .
5
Federal and foreign income, war profits, and excess profits taxes not deducted in figuring
line 1 (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 . . . . . . . . . . . . . .
6
Contributions deductible under section 545(b)(2). See instructions for limitation . . . . . . .6 . . . . . . . . . . . . . .
7
Net operating loss for the preceding tax year deductible under section 545(b)(4) . . . . . . 7. . . . . . . . . . . . . .
8 a Net capital gain from Schedule D (Form 1120), line 13 . . . . .8a. . . . . . . . . . . . . . . . . . . . . . . . .
b Less: Income tax on this net capital gain (see section
545(b)(5)) (attach computation) . . . . . . . . . . . . . .8b. . . . . . . . 4,925
. . . 8c
. . . . . . . . .-4,925
. . . . . .
9
Deduction for dividends paid (other than dividends paid after the end of the tax year).
Enter amount from Part VI, line 5 . . . . . . . . . . . . . . . . . . . . . . . . . 9 . . . . . . . . . . . . . .
CO
PY
Additions
10
11
12
13
CL
IE
NT
Deductions
11-1111111
Note: If the information in Part II and Part IV is not submitted with the return, the limitation period for assessment and
collection of the PHC tax is any time within 6 years after the return is filed. See section 6501(f).
Part II
14
15 a
b
16
17
18 a
b
19 a
b
20
21
22
23
24
25
Part III
26
PHC tax. Multiply the amount on line 13 by the tax rate for undistributed PHC income (see
instructions). Enter the result here and on Schedule J, line 8, or on the proper line of the
appropriate tax return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
. . . . . . . . . . 0
. . . .
For Paperwork Reduction Act Notice, see the Instructions for Form 1120.
(HTA)
Part IV
11-1111111
Page
(b) Address
(c) Preferred
(d) Common
St
Zip
St
Zip
St
Zip
St
Zip
Add the amounts in columns (c) and (d) and enter the totals here . . . . . . . . . . . . . . . . . .% . . . . . %
. . . . .
Part V
Excess of Expenses and Depreciation Over Income From Property Not Allowable
Under Section 545(b)(6) (see instructions for Part I, line 3)
(b) Date
acquired
(c) Cost or
other basis
(d) Depreciation
deduction
(e) Repairs,
insurance, and
other expenses
(section 162)
(attach schedule)
(f) Total of
columns (d)
and (e)
(h) Excess
(col. (f) less
col. (g))
CL
IE
NT
(a) Description of
property
Zip
CO
PY
St
Total excess of expenses and depreciation over rent or other compensation. Add the amounts in column
(h). Enter the total here and on Part I, line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. . . .
Note: Attach a statement showing the names and addresses of persons from whom rent or other
compensation was received for the use of, or the right to use, each property.
Part VI
Taxable dividends paid. Do not include dividends considered as paid in the preceding tax
year under section 563 or deficiency dividends as defined in section 547 . . . . . . . . . . . 1 . . . . . . . . . . . . . .
Dividend carryover from first and second preceding tax years. Attach computation . . . . . . . 4. . . . . . . . . . . . . .
Deduction for dividends paid. Add lines 3 and 4. Enter the total here and on Part I,
line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. . . . . . . . . . 0. . . . .
Schedule PH (Form 1120) (Rev. 12-2011)
Form
1125-E
(December 2011)
Department of the Treasury
Internal Revenue Service
Compensation of Officers
OMB No. 1545-2225
Name
11-1111111
Note. Complete Form 1125-E only if total receipts are $500,000 or more. See instructions for definition of total receipts.
Belinda Jackson
Ahmad Sharma
(c) Percent of
time devoted to
business
123-45-6789
50.00%
987-65-4321
50.00%
(e) Preferred
50.00%
50.00%
NT
CO
P
CL
IE
(f) Amount of
compensation
125,000
125,000
Subtract line 3 from line 2. Enter the result here and on Form 1120, page 1, line 12 or the
appropriate line of your tax return . . . . . . . . . . . . . . . . . . . . . . . . . . .4 . . . . . . . . .0 . . . .
11-1111111
1 Dividends paid in cash on stock held by an employee stock ownership plan (see instructions) . . . . . 1. . . . . 20,000
. . . . . . . .
2 Travel, Meals and Entertainment
a Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
. . . . . .6,300
. . . . . . .
b Meals and entertainment, subject to 50% limit . . . . . . . . . . . . . . .2b. . . . . 7,600
. . . . . . . . . . . . . . .
c Meals and entertainment, subject to 80% limit (DOT) . . . . . . . . . . . . 2c. . . . . . . . . . . . . . . . . . . . .
d Less disallowed . . . . . . . . . . . . . . . . . . . . . . . . . . 2d
. . . . . .3,800
. . . . . . . . . . . . . . .
e Subtract line d from lines b and c . . . . . . . . . . . . . . . . . . . . . . . . . . . .2e. . . . . 3,800
. . . . . . .
3 Dues and subscriptions
3
4,900
4 Insurance
4
15,000
5 Legal and professional fees
5
12,500
6 Miscellaneous
6
3,000
7 Telephone
7
2,400
8 Total other deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 . . . . 67,900
. . . . . . . .
9 Total deductions less expenses for offsetting credits . . . . . . . . . . . . . . . . . . . . . . 9 . . . . .67,900
. . . . . . .
T
N
E
I
L
C
Y
P
O
C
Beginning
End
1 Other Assets
1
2,980
2,110
2 Total other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. . . . . 2,980
. . . . . . . . .2,110
. . . . . . .
Beginning
End
1 Other Current Liabilities
1
9,350
18,250
2 Total other current liabilities . . . . . . . . . . . . . . . . . . . . . . . 2. . . . . .9,350
. . . . . . . 18,250
. . . . . . . .
11-1111111
1 Salaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. . . . . 5,000
. . . . . . . . . . . . . . . .
2 Wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 . . . . . . . . . . . . . . . . . . . .
3
3
4 Total salaries and wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 . . . . .5,000
. . . . . . .
Salaries and wages reported elsewhere on return:
5 Amounts included in Cost of Goods Sold . . . . . . . . . . . . . . . . . . .5 . . . . . . .0 . . . . . . . . . . . . .
6 Elective contributions to a section 401(k) cash or deferred
arrangement, or amounts contributed under a salary reductions SEP
agreement or a SIMPLE IRA plan . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . . . . . . . . . . . . . . .
7 Total salaries and wages reported elsewhere on return . . . . . . . . . . . . . . . . . . . . . 7. . . . . . . 0. . . . . .
Less employment credits:
8 From Form 5884 - Work Opportunity Credit . . . . . . . . . . . . . . . . . 8. . . . . . . 0. . . . . . . . . . . . . .
9 From Form 8844 - Empowerment Zone Employment Credit . . . . . . . . . . . 9 . . . . . . . 0 . . . . . . . . . . . . .
10 From Form 8845 - Indian Employment Credit . . . . . . . . . . . . . . . . 10
. . . . . . . 0. . . . . . . . . . . . . .
11
11
12
12
13 Total employment credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
. . . . . . . 0. . . . . .
14 Reduction of expenses for other offsetting credits (see attached statement) . . . . . . . . . . . . .14. . . . . . .0 . . . . .
15 Total salaries and wages less employment credits and expense reductions . . . . . . . . . . . . . 15. . . . . 5,000
. . . . . . .
I
L
T
N
E
Y
P
O
C
11-1111111
Amount
(C)
Deduction
Allowed in
Current Year
(D)
Contribution
Carryover
PY
1
a
b
2
a
b
c
d
e
3
4
5
(B)
Adjustment
under Section
170(d)(2)(B)
CO
6
7
8
9
10
CL
IE
NT
. . . . . . 17
. . . . . . . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
. .
. 0.
. .
. .
. .
. .
.
.
.
.
.
.
. .
. 18
.
.19.
.20.
.21.
.22.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. .
. 0.
. 0.
.0 .
.0 .
.0 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. .
. .
.
.
.
.
Part I - Contribution carryover, NOL carryover, and Taxable income without contribution deduction
1 2011 taxable income without contributions deduction . . . . . . . . . . . . . . . . . . . . . . 1. . . . 319,030
. . . . . . . .
2 Contribution deduction available in 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. . . . . 1,000
. . . . . . .
3 Prior year NOL carryover to 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 . . . . . . .0 . . . . .
Part III - Determination of 2011 contribution carryover to next year under Section 170(d)(2)(B)
1
2
3
4
5
11-1111111
No
X Is this tax year the corporation's first year in existence?
If "Yes", Stop here.
The corporation is exempt from AMT with no other qualification requirements.
Y
P
O
C
X Did the corporation lose small corporation status in a prior year? If so, enter the change date:
If "Yes", Stop here.
Once a corporation loses its small corporation status, it cannot qualify in any subsequent tax year.
Tax Year
2005
2006
2007
2008
2009
2010
2011
Yes
or
N/A
X
Annualized
Gross Receipts
T
N
E
I
L
530,000
No
Prior Three
Year Average
0
0
0
0
0
0
0
Did the corporation have average annual gross receipts of $5 million or less for the FIRST
three-year period beginning after 1993 (for calendar year corps in existence on 1/1/1994
through 1996)?
Were the corporation's average gross receipts for EVERY three-year period beginning after
1994 and ending before its tax year beginning in 2011 $7.5 million or less? (For calendar
year corporations in existence on 1/1/1994, the three year periods are: 1995-1997, 1996-1998,
1997-1999, 1998-2000, 1999-2001, 2000-2002, 2001-2003, 2002-2004, 2003-2005, 2004-2006, 2005-2007,
2006-2008, 2007-2009, 2008-2010).
If the corporation had only one prior tax year, were the gross receipts for the prior tax
year $5 million or less, (or the corporation was established before 1994)?
Corporation qualifies as a small corporation or is otherwise exempt from the alternative minimum tax.
11-1111111
Assets
Beginning
Ending
Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 . . . . 23,220
. . . . . . . . 26,300
. . . . . . . .
Trade notes and accounts receivable . . . . . . . . . . . . . . . . . . .2a. . . . .35,850
. . . . . . . .32,100
. . . . . . .
Less allowance for bad debts . . . . . . . . . . . . . . . . . . . . . .2b. . . . . . . . . . . . . . . . . . . . .
Net trade notes and accounts receivable . . . . . . . . . . . . . . . . . . 2c. . . . .35,850
. . . . . . . . 32,100
. . . . . . . .
Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. . . . . . . 0. . . . . . . . 0. . . . . .
U.S. government obligations . . . . . . . . . . . . . . . . . . . . . . 4. . . . . . . . . . . . . . . . . . . . .
Tax-exempt securities . . . . . . . . . . . . . . . . . . . . . . . . . 5 . . . . .75,000
. . . . . . . .75,000
. . . . . . .
Other current assets . . . . . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . 0
. . . . . . . . 0
. . . . . .
Loans to shareholders . . . . . . . . . . . . . . . . . . . . . . . . . 7. . . . . . . . . . . . . . . . . . . . .
Mortgage and real estate loans . . . . . . . . . . . . . . . . . . . . . 8. . . . . . . . . . . . . . . . . . . . .
Other investments . . . . . . . . . . . . . . . . . . . . . . . . . . 9. . . . . . . 0. . . . . . . . 0. . . . . .
Buildings and other depreciable assets . . . . . . . . . . . . . . . . . .10a
. . . . 295,600
. . . . . . . . 311,700
. . . . . . . . .
Less accumulated depreciation . . . . . . . . . . . . . . . . . . . . .10b
. . . . .-63,500
. . . . . . . .-85,900
. . . . . . . .
Net buildings and other depreciable assets . . . . . . . . . . . . . . . . 10c
. . . . . 232,100
. . . . . . . . 225,800
. . . . . . . .
Depletable assets . . . . . . . . . . . . . . . . . . . . . . . . . . 11a
. . . . . . . . . . . . . . . . . . . . .
Less accumulated depletion . . . . . . . . . . . . . . . . . . . . . . 11b
. . . . . . . . . . . . . . . . . . . . .
Net depletable assets . . . . . . . . . . . . . . . . . . . . . . . . .11c
. . . . . . . 0 . . . . . . . . 0. . . . . .
Land (net of any amortization) . . . . . . . . . . . . . . . . . . . . . 12
. . . . . 35,000
. . . . . . . . 35,000
. . . . . . . .
Intangible assets (amortizable only) . . . . . . . . . . . . . . . . . . . 13a
. . . . . . . 0
. . . . . . . . 0
. . . . . .
Less accumulated amortization . . . . . . . . . . . . . . . . . . . . .13b
. . . . . . . 0. . . . . . . . 0. . . . . .
Net intangible assets . . . . . . . . . . . . . . . . . . . . . . . . . 13c
. . . . . . . 0. . . . . . . . 0. . . . . .
Other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
. . . . . .2,980
. . . . . . . . 2,110
. . . . . . .
Total assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15. . . . 404,150
. . . . . . . . 396,310
. . . . . . . .
16
17
18
19
20
21
22a
22b
22c
23
24
25
26
27
28
Accounts payable . . . . . . . . . . . . . . . . . . . . . . . . . . 16
. . . . . 34,800
. . . . . . . . 35,596
. . . . . . . .
Mortgages, notes, bonds payable in less than 1 year . . . . . . . . . . . . . 17
. . . . . . . . . . . . . . . . . . . . .
Other current liabilities . . . . . . . . . . . . . . . . . . . . . . . . 18
. . . . . . 9,350
. . . . . . . 18,250
. . . . . . . .
Loans from shareholders . . . . . . . . . . . . . . . . . . . . . . . 19
. . . . . . . . . . . . . . . . . . . . .
Mortgages, notes, bonds payable in 1 year or more . . . . . . . . . . . . . .20. . . . 114,000
. . . . . . . . 108,600
. . . . . . . .
Other liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . .21. . . . . . .0 . . . . . . . .0 . . . . .
Capital stock (preferred) . . . . . . . . . . . . . . . . . . . . . . . .22a
. . . . . . . . . . . . . . . . . . . . .
Capital stock (common) . . . . . . . . . . . . . . . . . . . . . . . .22b
. . . . 200,000
. . . . . . . . 200,000
. . . . . . . . .
Net Capital Stock . . . . . . . . . . . . . . . . . . . . . . . . . . .22c
. . . . 200,000
. . . . . . . . 200,000
. . . . . . . . .
Additional paid-in capital . . . . . . . . . . . . . . . . . . . . . . . .23. . . . . . . . . . . . . . . . . . . .
Retained earnings - appropriated . . . . . . . . . . . . . . . . . . . . 24
. . . . . . . 0
. . . . . . . . 0
. . . . . .
Retained earnings - unappropriated . . . . . . . . . . . . . . . . . . . 25
. . . . . 46,000
. . . . . . . . 33,864
. . . . . . . .
Adjustments to shareholders' equity . . . . . . . . . . . . . . . . . . . 26
. . . . . . . 0. . . . . . . . 0. . . . . .
Less cost of treasury stock . . . . . . . . . . . . . . . . . . . . . . . 27. . . . . . . . . . . . . . . . . . . . .
Total liabilities and shareholders' equity . . . . . . . . . . . . . . . . . .28. . . . 404,150
. . . . . . . . 396,310
. . . . . . . . .
N
IE
L
C
Y
P
O
11-1111111
f
4
a
b
c
d
e
f
5
a
b
c
d
e
f
6
7
8
9
10
CO
PY
c
3
a
b
c
d
e
Pre-adjustment AMTI. Enter the amount from line 3 of Form 4626 . . . . . . . . . . . . . . . . 1. . . . 295,630
. . . . . . . . .
ACE depreciation adjustment:
AMT depreciation . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
. . . . . . . 0. . . . . . . . . . . . . .
ACE depreciation:
(1) Post-1993 property . . . . . . . . . . . . . . . . 2b1
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Post-1989, pre-1994 property . . . . . . . . . . . . 2b2
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Pre-1990 MACRS property . . . . . . . . . . . . . 2b3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) Pre-1990 original ACRS property . . . . . . . . . . . 2b4
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(5) Property described in sections 168(f)(1)
through (4) . . . . . . . . . . . . . . . . . . . .2b5
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(6) Other property . . . . . . . . . . . . . . . . . . 2b6
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(7) Total ACE depreciation. Add lines 2b(1) through 2b(6) . . . . . . . . . . .2b7
. . . . . . . 0. . . . . . . . . . . . . .
ACE depreciation adjustment. Subtract line 2b(7) from line 2a . . . . . . . . . . . . . . . . . .2c. . . . . . .0 . . . . .
Inclusion in ACE of items included in earnings and profits (E&P):
Tax-exempt interest income . . . . . . . . . . . . . . . . . . . . . . . 3a
. . . . . 3,000
. . . . . . . . . . . . . . . .
Death benefits from life insurance contracts . . . . . . . . . . . . . . . . . 3b. . . . . . . . . . . . . . . . . . . . .
All other distributions from life insurance contracts (including surrenders) . . . . . 3c
. . . . . . . . . . . . . . . . . . . . .
Inside buildup of undistributed income in life insurance contracts . . . . . . . . .3d. . . . . . . . . . . . . . . . . . . .
Other items (see Regulations sections 1.56(g)-1(c)(6)(iii) through (ix) for a
partial list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3e
. . . . . . . . . . . . . . . . . . . . .
Total increase to ACE from inclusion in ACE of items included in E&P. Add lines 3a through 3e . . . . .3f . . . . . 3,000
. . . . . . .
Disallowance of items not deductible from E&P:
Certain dividends received . . . . . . . . . . . . . . . . . . . . . . . .4a. . . . . . . . . . . . . . . . . . . .
Dividends paid on certain preferred stock of public utilities that are deductible
under section 247 . . . . . . . . . . . . . . . . . . . . . . . . . . . 4b
. . . . . . . . . . . . . . . . . . . . .
Dividends paid to an ESOP that are deductible under section 404(k) . . . . . . . 4c
. . . . . . . . . . . . . . . . . . . . .
Nonpatronage dividends that are paid and deductible under section
1382(c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4d
. . . . . . . . . . . . . . . . . . . . .
Other items (see Regulations sections 1.56(g)-1(d)(3)(i) and (ii) for a
partial list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4e
. . . . . . . . . . . . . . . . . . . . .
Total increase to ACE because of disallowance of items not deductible from E&P.
Add lines 4a through 4e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4f. . . . . . . 0 . . . . .
Other adjustments based on rules for figuring E&P:
Intangible drilling costs . . . . . . . . . . . . . . . . . . . . . . . . . 5a
. . . . . . . . . . . . . . . . . . . . .
Circulation expenditures . . . . . . . . . . . . . . . . . . . . . . . . 5b
. . . . . . . . . . . . . . . . . . . . .
Organizational expenditures . . . . . . . . . . . . . . . . . . . . . . . 5c. . . . . . . . . . . . . . . . . . . . .
LIFO inventory adjustments . . . . . . . . . . . . . . . . . . . . . . . 5d
. . . . . . . . . . . . . . . . . . . . .
Installments sales . . . . . . . . . . . . . . . . . . . . . . . . . . . 5e
. . . . . . . . . . . . . . . . . . . . .
Total other E&P adjustments. Combine lines 5a through 5e . . . . . . . . . . . . . . . . . . .5f . . . . . . .0 . . . . .
Disallowance of loss on exchange of debt pools . . . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . . . . . . .
Acquisition expenses of life insurance companies for qualified foreign contracts . . . . . . . . . . . 7. . . . . . . . . . . .
Depletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 . . . . . . . . . . . .
Basis adjustments in determining gain or loss from sale or exchange of pre-1994 property . . . . . . . 9 . . . . . . . . . . . .
Adjusted current earnings. Combine lines 1, 2c, 3f, 4f, and 5f through 9. Enter the result here
and on line 4a of Form 4626 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
. . . . 298,630
. . . . . . . . .
CL
IE
NT
1
2
a
b
Form
1120
. . . . . . . . . . By
. . the
. . Numbers,
. . . . . Inc.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1111111
. . . . .
TYPE
Number, street, and room or suite no. If a P.O. box, see instructions.
C Date incorporated
. . . . OR
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Before
. . . .1900,
. . .see
. Options tab.
8/8/2005
. . . . . . . . . . .City
. or
. town
. . . . . . . . . . . . . State
. . . . . . . . . . ZIP
. .code
. . . . . . D
. . Total
. . assets
. . . (see
. . instructions)
.
. . . . . . . . . . Los
. . Angeles
. . . . . . . . . . . . . . CA
. . . . . . . . . . 90012
. . . . . . . . $
. . . . . . . . . .
E Check if:
(1)
Initial return
(2)
Final return
(3)
396,310
Address change
1a
b
c
d
e
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29a
b
c
30
31
32
33
34
35
36
Sign
Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct,
and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
11/29/2012
Signature of officer
Print/Type preparer's name
Paid
Preparer
Use Only
Date
Neda B. Ardekani
Title
Preparer's signature
Date
SELF-PREPARED RETURN
Firm's name
City
PTIN
Firm's EIN
Firm's address
, ending
Name
Income
Phone no.
State
ZIP code
Form
1120 (2011)
Schedule C
11-1111111
(a) Dividends
received
(b) %
Page
see
Dividends on debt-financed stock of domestic and foreign corporations . . . . . . . . . . . . . . . . . . instructions
. . . . . . . . . . . . . 0. . . .
10
. . . . . . . . . . . . . . . . . . . 100
. . . . . . . . . . . . 0. . . .
11
12
13
14
Income from controlled foreign corporations under subpart F (attach Form(s) 5471) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
16
17
Other dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
19
Total dividends. Add lines 1 through 17. Enter here and on page 1, line 4 . . . . . . . . . . . . . . . .0 . . . . . . . . . . . . . . . . . .
20
Total special deductions. Add lines 9, 10, 11, 12, and 18. Enter here and on page 1, line 29b . . . . . . . . . . . . . . . . . . . . . . 0. . . .
Form
1120 (2011)
Schedule J
11-1111111
Page 3
Check if the corporation is a member of a controlled group (attach Schedule O (Form 1120)) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Income tax. Check if a qualified personal service corporation (see instructions) . . . . . .. . .. . . . . . . . .. .. . .. . . X. . . . . .2. . . . . 103,471
. . . . . . . . .
10
11
13
14
15
16
17
18
19
a
b
c
d
20
21
Schedule K
X Cash
Accrual
Yes
Other (specify)
No
541990
actuarial
actuarial
EIN
Name
a Did any foreign or domestic corporation, partnership (including any entity treated as a partnership), trust, or tax-exempt
organization own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all classes of the
corporation's stock entitled to vote? If "Yes," complete Part I of Schedule G (Form 1120) (attach Schedule G) . . . . . . . . . . . . . . . . . X. . . .
b Did any individual or estate own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all
classes of the corporation's stock entitled to vote? If "Yes," complete Part II of Schedule G (Form 1120) (attach Schedule G) . . . . . . . . . X. . . . . .
Form
1120 (2011)
Schedule K
11-1111111
Page 4
No
a Own directly 20% or more, or own, directly or indirectly, 50% or more of the total voting power of all classes of stock entitled to vote of any
foreign or domestic corporation not included onForm 851, Affiliations Schedule? For rules of constructive ownership, see instructions.
If "Yes," complete (i) through (iv) below.
(ii) Employer
Identification Number
(if any)
(iii) Country of
Incorporation
(iv) Percentage
Owned in Voting
Stock
b Own directly an interest of 20% or more, or own, directly or indirectly, an interest of 50% or more in any foreign or domestic partnership
(including an entity treated as a partnership) or in the beneficial interest of a trust? For rules of constructive ownership, see instructions . . . . . . . X. . . .
If "Yes," complete (i) through (iv) below.
(ii) Employer
Identification Number
(if any)
(iv) Maximum
Percentage Owned in
Profit, Loss, or Capital
During this tax year, did the corporation pay dividends (other than stock dividends and distributions in exchange for stock) in
excess of the corporation's current and accumulated earnings and profits? (See sections 301 and 316.) . . . . . . . . . . . . . . . . . . . X
. . . .
If "Yes," file Form 5452, Corporate Report of Nondividend Distributions.
If this is a consolidated return, answer here for the parent corporation and on Form 851 for each subsidiary.
At any time during the tax year, did one foreign person own, directly or indirectly, at least 25%(a)
of the total voting power of all
classes of the corporation's stock entitled to vote or(b) the total value of all classes of the corporation's stock? . . . . . . . . . . . . . . . . . X
. . . .
For rules of attribution, see section 318. If "Yes," enter:
(i) Percentage owned
(c) The corporation may have to fileForm 5472, Information Return of a 25% Foreign-Owned U.S. Corporation or a Foreign
Corporation Engaged in a U.S. Trade or Business. Enter the number of Forms 5472 attached
8
Check this box if the corporation issued publicly offered debt instruments with original issue discount . . . . . . . . . . . . . . . . . . . . . . . . .
If checked, the corporation may have to fileForm 8281, Information Return for Publicly Offered Original Issue Discount Instruments.
Enter the amount of tax-exempt interest received or accrued during the tax year
$
3,000
2
10
Enter the number of shareholders at the end of the tax year (if 100 or fewer)
11
If the corporation has an NOL for the tax year and is electing to forego the carryback period, check here . . . . . . . . . . . . . . . . . . . . . . .
If the corporation is filing a consolidated return, the statement required by Regulations section 1.1502-21(b)(3) must be attached or
the election will not be valid.
12
Enter the available NOL carryover from prior tax years (do not reduce it by any deduction on line 29a.)
13
Are the corporation's total receipts (line 1c plus lines 4 through 10 on page 1) for the tax year
and its total assets at the end of the
tax year less than $250,000? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X. . . .
If "Yes," the corporation is not required to complete Schedules L, M-1, and M-2 on page 5. Instead, enter the total amount of cash
distributions and the book value of property distributions (other than cash) made during the tax year.
$
14
Is the corporation required to file Schedule UTP (Form 1120), Uncertain Tax Position Statement (see instructions)? . . . . . . . . . . . . . . . . . . .
If "Yes," complete and attach Schedule UTP.
15a Did the corporation make any payments in 2011 that would require it to file Form(s) 1099 (see instructions)? . . . . . . . . . . . . . . . . . .X . . . .
b If "Yes," did or will the corporation file all required Forms 1099? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Form
1120 (2011)
Schedule L
11-1111111
Beginning of tax year
(a)
(b)
Page 5
(d)
1
2a
b
3
4
5
6
7
8
9
10a
b
11a
b
12
13a
b
14
15
Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23,220
. . . . . . . . . . . . . . . . . . 26,300
. . . . . . .
Trade notes and accounts receivable . . . . . . . . . . . . . .35,850
. . . . . . . . . . . . . . . . . .32,100
. . . . . . . . . . . . . . . .
Less allowance for bad debts . . . . . . . . . . . . (. . . . . . . .) . . . . . . 35,850
. . . . (. . . . . . . .) . . . . . . 32,100
. . . . . . .
Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
U.S. government obligations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax-exempt securities (see instructions) . . . . . . . . . . . . . . . . . . . . . .75,000
. . . . . . . . . . . . . . . . . .75,000
. . . . . . .
Other current assets (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Loans to shareholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mortgage and real estate loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other investments (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Buildings and other depreciable assets . . . . . . . . . . . . 295,600
. . . . . . . . . . . . . . . . . . 311,700
. . . . . . . . . . . . . . . . . .
Less accumulated depreciation . . . . . . . . . . . .( . . . . 63,500)
. . . . . . . . 232,100
. . . . . (. . . . . 85,900)
. . . . . . . . .225,800
. . . . . . . .
Depletable assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Less accumulated depletion . . . . . . . . . . . . .( . . . . . . . ). . . . . . . . . 0 . .( . . . . . . . ). . . . . . . . . 0. . . . .
Land (net of any amortization) . . . . . . . . . . . . . . . . . . . . . . . . . 35,000
. . . . . . . . . . . . . . . . . . .35,000
. . . . . . .
Intangible assets (amortizable only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Less accumulated amortization . . . . . . . . . . . (. . . . . . . . ) . . . . . . . . .0 . (. . . . . . . . ) . . . . . . . . .0 . . . . .
Other assets (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . .2,980
. . . . . . . . . . . . . . . . . . 2,110
. . . . . . .
Total assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404,150
. . . . . . . . . . . . . . . . . . 396,310
. . . . . . . .
16
17
18
19
20
21
22
23
24
25
26
27
28
Schedule M-1
0
3,800 9 Add lines 7 and 8 . . . . . . . . . . . . . . . . .3,000
. . . . . .
Add lines 1 through 5 . . . . . . . . . . . . . . . . . . 298,630
. . . . 10
. . Income
. . . (page
. . . 1,. line
. .28)line
. . . 6
. less
. . line
. .9 . . . . . 295,630
. . . . . . . .
Schedule M-2
1
2
3
1120 (2011)
Form
4626
Name
4
a
b
c
d
5
6
7
Alternative minimum taxable income. Subtract line 6 from line 5. If the corporation held a residual
interest in a REMIC, see instructions . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. .. .. .. 7. . . . . . . . 297,880
.. .. .. .. .. .. ..
8
a
Exemption phase-out (if line 7 is $310,000 or more, skip lines 8a and 8b and enter -0- on line 8c):
Subtract $150,000 from line 7 (if completing this line for a member of a
controlled group, see instructions). If zero or less, enter -0- . . . . . . . . . . 8a
. . . . . 147,880
. . . . . . . . . . . . . . .
Multiply line 8a by 25% (.25) . . . . . . . . . . . . . . . . . . . . . . 8b
. . . . . .36,970
. . . . . . . . . . . . . .
Exemption. Subtract line 8b from $40,000 (if completing this line for a member of a controlled group,
see instructions). If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . 8c
. . . . . .3,030
. . . . .
Subtract line 8c from line 7. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . 9. . . . .294,850
. . . . . .
Multiply line 9 by 20% (.20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10. . . . .58,970
. . . . . .
Alternative minimum tax foreign tax credit (AMTFTC) (see instructions) . . . . . . . . . . . . . . 11
. . . . . . . . . . . .
Tentative minimum tax. Subtract line 11 from line 10 . . . . . . . . . . . . . . .. .. .. .. .. .. .. ..12. . . . . . . . .58,970
.. .. .. .. .. ..
Regular tax liability before applying all credits except the foreign tax credit . . . . . . . . . . . . . .13. . . . 103,471
. . . . . . .
Alternative minimum tax. Subtract line 13 from line 12. If zero or less, enter -0-. Enter here and on
Form 1120, Schedule J, line 3, or the appropriate line of the corporation's income tax return . . . . . . 14
. . . . . . . 0. . . .
b
c
9
10
11
12
13
14
Form
4626 (2011)
SCHEDULE G
(Form 1120)
Name
Part I
11-1111111
Certain Entities Owning the Corporation's Voting Stock. (Form 1120, Schedule K, Question 4a).
Complete columns (i) through (v) below for any foreign or domestic corporation, partnership (including
any entity treated as a partnership), trust, or tax-exempt organization that owns directly 20% or more, or
owns, directly or indirectly, 50% or more of the total voting power of all classes of the corporation's
stock entitled to vote (see instructions).
(i) Name of Entity
Part II
OMB No.1545-0123
Certain Individuals and Estates Owning the Corporation's Voting Stock. (Form 1120, Schedule K,
Question 4b). Complete columns (i) through (iv) below for any individual or estate that owns directly 20%
or more, or owns, directly or indirectly, 50% or more of the total voting power of all classes of the
corporation's stock entitled to vote (see instructions).
(i) Name of Individual or Estate
(ii) Identifying
Number (if any)
(iii) Country of
Citizenship (see
instructions)
Belinda Jackson
123-45-6789
United States
50.000%
Ahmad Sharma
987-65-4321
United States
50.000%
SCHEDULE PH
(Form 1120)
Name
Part I
Taxable income before net operating loss deduction and special deductions. Enter
amount from Form 1120, line 28 . . . . . . . . . . . . . . . . . . . . . . . . . 1. . . . . . . 295,630
. . . . . . .
2
Contributions deducted in figuring line 1. Enter amount from Form 1120, line 19 . . . . . . 2
. . . . . . . . . 1,000
. . . . .
3
Excess expenses and depreciation under section 545(b)(6). Enter amount from Part V,
line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 . . . . . . . . . . . . . .
4
Total. Add lines 1 through 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. . . . . . . 296,630
. . . . . . .
5
Federal and foreign income, war profits, and excess profits taxes not deducted in figuring
line 1 (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 . . . . . . . . . . . . . .
6
Contributions deductible under section 545(b)(2). See instructions for limitation . . . . . . .6 . . . . . . . . . . . . . .
7
Net operating loss for the preceding tax year deductible under section 545(b)(4) . . . . . . 7. . . . . . . . . . . . . .
8 a Net capital gain from Schedule D (Form 1120), line 13 . . . . .8a. . . . . . . . . . . . . . . . . . . . . . . . .
b Less: Income tax on this net capital gain (see section
545(b)(5)) (attach computation) . . . . . . . . . . . . . .8b. . . . . . . . 4,925
. . . 8c
. . . . . . . . .-4,925
. . . . . .
9
Deduction for dividends paid (other than dividends paid after the end of the tax year).
Enter amount from Part VI, line 5 . . . . . . . . . . . . . . . . . . . . . . . . . 9 . . . . . . . . . . . . . .
Additions
Deductions
11-1111111
10
11
12
13
Note: If the information in Part II and Part IV is not submitted with the return, the limitation period for assessment and
collection of the PHC tax is any time within 6 years after the return is filed. See section 6501(f).
Part II
14
15 a
b
16
17
18 a
b
19 a
b
20
21
22
23
24
25
Part III
26
PHC tax. Multiply the amount on line 13 by the tax rate for undistributed PHC income (see
instructions). Enter the result here and on Schedule J, line 8, or on the proper line of the
appropriate tax return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
. . . . . . . . . . 0
. . . .
For Paperwork Reduction Act Notice, see the Instructions for Form 1120.
(HTA)
Part IV
11-1111111
Page
(b) Address
(c) Preferred
(d) Common
St
Zip
St
Zip
St
Zip
St
Zip
St
Zip
Add the amounts in columns (c) and (d) and enter the totals here . . . . . . . . . . . . . . . . . .% . . . . . %
. . . . .
Part V
Excess of Expenses and Depreciation Over Income From Property Not Allowable
Under Section 545(b)(6) (see instructions for Part I, line 3)
(a) Description of
property
(b) Date
acquired
(c) Cost or
other basis
(d) Depreciation
deduction
(e) Repairs,
insurance, and
other expenses
(section 162)
(attach schedule)
(f) Total of
columns (d)
and (e)
(h) Excess
(col. (f) less
col. (g))
Total excess of expenses and depreciation over rent or other compensation. Add the amounts in column
(h). Enter the total here and on Part I, line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. . . .
Note: Attach a statement showing the names and addresses of persons from whom rent or other
compensation was received for the use of, or the right to use, each property.
Part VI
Taxable dividends paid. Do not include dividends considered as paid in the preceding tax
year under section 563 or deficiency dividends as defined in section 547 . . . . . . . . . . . 1 . . . . . . . . . . . . . .
Dividend carryover from first and second preceding tax years. Attach computation . . . . . . . 4. . . . . . . . . . . . . .
Deduction for dividends paid. Add lines 3 and 4. Enter the total here and on Part I,
line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. . . . . . . . . . 0. . . . .
Schedule PH (Form 1120) (Rev. 12-2011)
Form
1125-E
(December 2011)
Department of the Treasury
Internal Revenue Service
Compensation of Officers
OMB No. 1545-2225
Name
11-1111111
Note. Complete Form 1125-E only if total receipts are $500,000 or more. See instructions for definition of total receipts.
(a) Name of officer
Belinda Jackson
Ahmad Sharma
(c) Percent of
time devoted to
business
(e) Preferred
(f) Amount of
compensation
123-45-6789
50.00%
50.00%
125,000
987-65-4321
50.00%
50.00%
125,000
Subtract line 3 from line 2. Enter the result here and on Form 1120, page 1, line 12 or the
appropriate line of your tax return . . . . . . . . . . . . . . . . . . . . . . . . . . .4 . . . . . . . . .0 . . . .
11-1111111
1 Dividends paid in cash on stock held by an employee stock ownership plan (see instructions) . . . . . 1. . . . . 20,000
. . . . . . . .
2 Travel, Meals and Entertainment
a Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
. . . . . .6,300
. . . . . . .
b Meals and entertainment, subject to 50% limit . . . . . . . . . . . . . . .2b. . . . . 7,600
. . . . . . . . . . . . . . .
c Meals and entertainment, subject to 80% limit (DOT) . . . . . . . . . . . . 2c. . . . . . . . . . . . . . . . . . . . .
d Less disallowed . . . . . . . . . . . . . . . . . . . . . . . . . . 2d
. . . . . .3,800
. . . . . . . . . . . . . . .
e Subtract line d from lines b and c . . . . . . . . . . . . . . . . . . . . . . . . . . . .2e. . . . . 3,800
. . . . . . .
3 Dues and subscriptions
3
4,900
4 Insurance
4
15,000
5 Legal and professional fees
5
12,500
6 Miscellaneous
6
3,000
7 Telephone
7
2,400
8 Total other deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 . . . . 67,900
. . . . . . . .
9 Total deductions less expenses for offsetting credits . . . . . . . . . . . . . . . . . . . . . . 9 . . . . .67,900
. . . . . . .
Beginning
End
1 Other Assets
1
2,980
2,110
2 Total other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. . . . . 2,980
. . . . . . . . .2,110
. . . . . . .
11-1111111
1 Salaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. . . . . 5,000
. . . . . . . . . . . . . . . .
2 Wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 . . . . . . . . . . . . . . . . . . . .
3
3
4 Total salaries and wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 . . . . .5,000
. . . . . . .
Salaries and wages reported elsewhere on return:
5 Amounts included in Cost of Goods Sold . . . . . . . . . . . . . . . . . . .5 . . . . . . .0 . . . . . . . . . . . . .
6 Elective contributions to a section 401(k) cash or deferred
arrangement, or amounts contributed under a salary reductions SEP
agreement or a SIMPLE IRA plan . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . . . . . . . . . . . . . . .
7 Total salaries and wages reported elsewhere on return . . . . . . . . . . . . . . . . . . . . . 7. . . . . . . 0. . . . . .
Less employment credits:
8 From Form 5884 - Work Opportunity Credit . . . . . . . . . . . . . . . . . 8. . . . . . . 0. . . . . . . . . . . . . .
9 From Form 8844 - Empowerment Zone Employment Credit . . . . . . . . . . . 9 . . . . . . . 0 . . . . . . . . . . . . .
10 From Form 8845 - Indian Employment Credit . . . . . . . . . . . . . . . . 10
. . . . . . . 0. . . . . . . . . . . . . .
11
11
12
12
13 Total employment credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
. . . . . . . 0. . . . . .
14 Reduction of expenses for other offsetting credits (see attached statement) . . . . . . . . . . . . .14. . . . . . .0 . . . . .
15 Total salaries and wages less employment credits and expense reductions . . . . . . . . . . . . . 15. . . . . 5,000
. . . . . . .
11-1111111
Amount
1
a
b
2
a
b
c
d
e
3
4
5
(B)
Adjustment
under Section
170(d)(2)(B)
(C)
Deduction
Allowed in
Current Year
(D)
Contribution
Carryover
. . . . . . 17
. . . . . . . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
. .
. 0.
. .
. .
. .
. .
.
.
.
.
.
.
. .
. 18
.
.19.
.20.
.21.
.22.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. .
. 0.
. 0.
.0 .
.0 .
.0 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. .
. .
.
.
.
.
Part I - Contribution carryover, NOL carryover, and Taxable income without contribution deduction
1 2011 taxable income without contributions deduction . . . . . . . . . . . . . . . . . . . . . . 1. . . . 319,030
. . . . . . . .
2 Contribution deduction available in 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. . . . . 1,000
. . . . . . .
3 Prior year NOL carryover to 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 . . . . . . .0 . . . . .
Part III - Determination of 2011 contribution carryover to next year under Section 170(d)(2)(B)
1
2
3
4
5
11-1111111
No
X Is this tax year the corporation's first year in existence?
If "Yes", Stop here.
The corporation is exempt from AMT with no other qualification requirements.
X Did the corporation lose small corporation status in a prior year? If so, enter the change date:
If "Yes", Stop here.
Once a corporation loses its small corporation status, it cannot qualify in any subsequent tax year.
Tax Year
2005
2006
2007
2008
2009
2010
2011
Yes
or
N/A
X
Annualized
Gross Receipts
530,000
Prior Three
Year Average
0
0
0
0
0
0
0
No
Did the corporation have average annual gross receipts of $5 million or less for the FIRST
three-year period beginning after 1993 (for calendar year corps in existence on 1/1/1994
through 1996)?
Were the corporation's average gross receipts for EVERY three-year period beginning after
1994 and ending before its tax year beginning in 2011 $7.5 million or less? (For calendar
year corporations in existence on 1/1/1994, the three year periods are: 1995-1997, 1996-1998,
1997-1999, 1998-2000, 1999-2001, 2000-2002, 2001-2003, 2002-2004, 2003-2005, 2004-2006, 2005-2007,
2006-2008, 2007-2009, 2008-2010).
If the corporation had only one prior tax year, were the gross receipts for the prior tax
year $5 million or less, (or the corporation was established before 1994)?
Corporation qualifies as a small corporation or is otherwise exempt from the alternative minimum tax.
11-1111111
Assets
Beginning
Ending
Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 . . . . 23,220
. . . . . . . . 26,300
. . . . . . . .
Trade notes and accounts receivable . . . . . . . . . . . . . . . . . . .2a. . . . .35,850
. . . . . . . .32,100
. . . . . . .
Less allowance for bad debts . . . . . . . . . . . . . . . . . . . . . .2b. . . . . . . . . . . . . . . . . . . . .
Net trade notes and accounts receivable . . . . . . . . . . . . . . . . . . 2c. . . . .35,850
. . . . . . . . 32,100
. . . . . . . .
Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. . . . . . . 0. . . . . . . . 0. . . . . .
U.S. government obligations . . . . . . . . . . . . . . . . . . . . . . 4. . . . . . . . . . . . . . . . . . . . .
Tax-exempt securities . . . . . . . . . . . . . . . . . . . . . . . . . 5 . . . . .75,000
. . . . . . . .75,000
. . . . . . .
Other current assets . . . . . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . 0
. . . . . . . . 0
. . . . . .
Loans to shareholders . . . . . . . . . . . . . . . . . . . . . . . . . 7. . . . . . . . . . . . . . . . . . . . .
Mortgage and real estate loans . . . . . . . . . . . . . . . . . . . . . 8. . . . . . . . . . . . . . . . . . . . .
Other investments . . . . . . . . . . . . . . . . . . . . . . . . . . 9. . . . . . . 0. . . . . . . . 0. . . . . .
Buildings and other depreciable assets . . . . . . . . . . . . . . . . . .10a
. . . . 295,600
. . . . . . . . 311,700
. . . . . . . . .
Less accumulated depreciation . . . . . . . . . . . . . . . . . . . . .10b
. . . . .-63,500
. . . . . . . .-85,900
. . . . . . . .
Net buildings and other depreciable assets . . . . . . . . . . . . . . . . 10c
. . . . . 232,100
. . . . . . . . 225,800
. . . . . . . .
Depletable assets . . . . . . . . . . . . . . . . . . . . . . . . . . 11a
. . . . . . . . . . . . . . . . . . . . .
Less accumulated depletion . . . . . . . . . . . . . . . . . . . . . . 11b
. . . . . . . . . . . . . . . . . . . . .
Net depletable assets . . . . . . . . . . . . . . . . . . . . . . . . .11c
. . . . . . . 0 . . . . . . . . 0. . . . . .
Land (net of any amortization) . . . . . . . . . . . . . . . . . . . . . 12
. . . . . 35,000
. . . . . . . . 35,000
. . . . . . . .
Intangible assets (amortizable only) . . . . . . . . . . . . . . . . . . . 13a
. . . . . . . 0
. . . . . . . . 0
. . . . . .
Less accumulated amortization . . . . . . . . . . . . . . . . . . . . .13b
. . . . . . . 0. . . . . . . . 0. . . . . .
Net intangible assets . . . . . . . . . . . . . . . . . . . . . . . . . 13c
. . . . . . . 0. . . . . . . . 0. . . . . .
Other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
. . . . . .2,980
. . . . . . . . 2,110
. . . . . . .
Total assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15. . . . 404,150
. . . . . . . . 396,310
. . . . . . . .
16
17
18
19
20
21
22a
22b
22c
23
24
25
26
27
28
Accounts payable . . . . . . . . . . . . . . . . . . . . . . . . . . 16
. . . . . 34,800
. . . . . . . . 35,596
. . . . . . . .
Mortgages, notes, bonds payable in less than 1 year . . . . . . . . . . . . . 17
. . . . . . . . . . . . . . . . . . . . .
Other current liabilities . . . . . . . . . . . . . . . . . . . . . . . . 18
. . . . . . 9,350
. . . . . . . 18,250
. . . . . . . .
Loans from shareholders . . . . . . . . . . . . . . . . . . . . . . . 19
. . . . . . . . . . . . . . . . . . . . .
Mortgages, notes, bonds payable in 1 year or more . . . . . . . . . . . . . .20. . . . 114,000
. . . . . . . . 108,600
. . . . . . . .
Other liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . .21. . . . . . .0 . . . . . . . .0 . . . . .
Capital stock (preferred) . . . . . . . . . . . . . . . . . . . . . . . .22a
. . . . . . . . . . . . . . . . . . . . .
Capital stock (common) . . . . . . . . . . . . . . . . . . . . . . . .22b
. . . . 200,000
. . . . . . . . 200,000
. . . . . . . . .
Net Capital Stock . . . . . . . . . . . . . . . . . . . . . . . . . . .22c
. . . . 200,000
. . . . . . . . 200,000
. . . . . . . . .
Additional paid-in capital . . . . . . . . . . . . . . . . . . . . . . . .23. . . . . . . . . . . . . . . . . . . .
Retained earnings - appropriated . . . . . . . . . . . . . . . . . . . . 24
. . . . . . . 0
. . . . . . . . 0
. . . . . .
Retained earnings - unappropriated . . . . . . . . . . . . . . . . . . . 25
. . . . . 46,000
. . . . . . . . 33,864
. . . . . . . .
Adjustments to shareholders' equity . . . . . . . . . . . . . . . . . . . 26
. . . . . . . 0. . . . . . . . 0. . . . . .
Less cost of treasury stock . . . . . . . . . . . . . . . . . . . . . . . 27. . . . . . . . . . . . . . . . . . . . .
Total liabilities and shareholders' equity . . . . . . . . . . . . . . . . . .28. . . . 404,150
. . . . . . . . 396,310
. . . . . . . . .
11-1111111
c
3
a
b
c
d
e
f
4
a
b
c
d
e
f
5
a
b
c
d
e
f
6
7
8
9
10
Pre-adjustment AMTI. Enter the amount from line 3 of Form 4626 . . . . . . . . . . . . . . . . 1. . . . 295,630
. . . . . . . . .
ACE depreciation adjustment:
AMT depreciation . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
. . . . . . . 0. . . . . . . . . . . . . .
ACE depreciation:
(1) Post-1993 property . . . . . . . . . . . . . . . . 2b1
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Post-1989, pre-1994 property . . . . . . . . . . . . 2b2
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Pre-1990 MACRS property . . . . . . . . . . . . . 2b3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) Pre-1990 original ACRS property . . . . . . . . . . . 2b4
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(5) Property described in sections 168(f)(1)
through (4) . . . . . . . . . . . . . . . . . . . .2b5
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(6) Other property . . . . . . . . . . . . . . . . . . 2b6
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(7) Total ACE depreciation. Add lines 2b(1) through 2b(6) . . . . . . . . . . .2b7
. . . . . . . 0. . . . . . . . . . . . . .
ACE depreciation adjustment. Subtract line 2b(7) from line 2a . . . . . . . . . . . . . . . . . .2c. . . . . . .0 . . . . .
Inclusion in ACE of items included in earnings and profits (E&P):
Tax-exempt interest income . . . . . . . . . . . . . . . . . . . . . . . 3a
. . . . . 3,000
. . . . . . . . . . . . . . . .
Death benefits from life insurance contracts . . . . . . . . . . . . . . . . . 3b. . . . . . . . . . . . . . . . . . . . .
All other distributions from life insurance contracts (including surrenders) . . . . . 3c
. . . . . . . . . . . . . . . . . . . . .
Inside buildup of undistributed income in life insurance contracts . . . . . . . . .3d. . . . . . . . . . . . . . . . . . . .
Other items (see Regulations sections 1.56(g)-1(c)(6)(iii) through (ix) for a
partial list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3e
. . . . . . . . . . . . . . . . . . . . .
Total increase to ACE from inclusion in ACE of items included in E&P. Add lines 3a through 3e . . . . .3f . . . . . 3,000
. . . . . . .
Disallowance of items not deductible from E&P:
Certain dividends received . . . . . . . . . . . . . . . . . . . . . . . .4a. . . . . . . . . . . . . . . . . . . .
Dividends paid on certain preferred stock of public utilities that are deductible
under section 247 . . . . . . . . . . . . . . . . . . . . . . . . . . . 4b
. . . . . . . . . . . . . . . . . . . . .
Dividends paid to an ESOP that are deductible under section 404(k) . . . . . . . 4c
. . . . . . . . . . . . . . . . . . . . .
Nonpatronage dividends that are paid and deductible under section
1382(c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4d
. . . . . . . . . . . . . . . . . . . . .
Other items (see Regulations sections 1.56(g)-1(d)(3)(i) and (ii) for a
partial list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4e
. . . . . . . . . . . . . . . . . . . . .
Total increase to ACE because of disallowance of items not deductible from E&P.
Add lines 4a through 4e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4f. . . . . . . 0 . . . . .
Other adjustments based on rules for figuring E&P:
Intangible drilling costs . . . . . . . . . . . . . . . . . . . . . . . . . 5a
. . . . . . . . . . . . . . . . . . . . .
Circulation expenditures . . . . . . . . . . . . . . . . . . . . . . . . 5b
. . . . . . . . . . . . . . . . . . . . .
Organizational expenditures . . . . . . . . . . . . . . . . . . . . . . . 5c. . . . . . . . . . . . . . . . . . . . .
LIFO inventory adjustments . . . . . . . . . . . . . . . . . . . . . . . 5d
. . . . . . . . . . . . . . . . . . . . .
Installments sales . . . . . . . . . . . . . . . . . . . . . . . . . . . 5e
. . . . . . . . . . . . . . . . . . . . .
Total other E&P adjustments. Combine lines 5a through 5e . . . . . . . . . . . . . . . . . . .5f . . . . . . .0 . . . . .
Disallowance of loss on exchange of debt pools . . . . . . . . . . . . . . . . . . . . . . . .6 . . . . . . . . . . . .
Acquisition expenses of life insurance companies for qualified foreign contracts . . . . . . . . . . . 7. . . . . . . . . . . .
Depletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 . . . . . . . . . . . .
Basis adjustments in determining gain or loss from sale or exchange of pre-1994 property . . . . . . . 9 . . . . . . . . . . . .
Adjusted current earnings. Combine lines 1, 2c, 3f, 4f, and 5f through 9. Enter the result here
and on line 4a of Form 4626 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
. . . . 298,630
. . . . . . . . .