Section 12. Exempt Organization Returns
Internal Revenue Manual Part 3. Submission Processing · 2026-10-03 edition · updated 2026-10-04 · United States
3.24.12 Exempt Organization Returns¶
Manual Transmittal¶
Purpose¶
(1) This transmits revised IRM 3.24.12, Integrated Submission and Remittance Processing (ISRP) System, Exempt Organization Returns.
Material Changes¶
(1) IRM 3.24.12.1.3 IPU 25U3373 issued 06-05-2025 - Updated Titles.
(2) IRM 3.24.12.1.6 IPU 25U3373 issued 06-05-2025 - Updated Titles.
(3) IRM 3.24.12.1.6 - Added acronym definition table.
(4) Exhibit 3.24.12-237 - Added Form 8050 Instructions.
(5) Exhibit 3.24.12-241 - Added lines 5b and 6k.
(6) Exhibit 3.24.12-255 - Added Form 8283 Instructions.
(7) Exhibit 3.24.12-258 - Added Form 8050 Instructions.
(8) Exhibit 3.24.12-274 - Added Form 8050 Instructions.
(9) IRM 3.24.12-276 IPU 25U3413 issued 06-18-2025 - Updated Sections (8) and (9).
(10) Exhibit 3.24.12-278 - Added Form 8050 Instructions.
(11) Updated Prompts and Lines throughout the IRM for clarity.
(12) Editorial changes have been made throughout the IRM for clarity. Reviewed and updated grammar, formatting, punctuation, links, titles, tax years/dates, website addresses and IRM references if needed.
Effect on Other Documents¶
Audience¶
Effective Date¶
Peggy L. Combs Acting Director, Business System Planning Government Entities and Shared Services Tax Exempt Government Entities
Program Scope and Objectives¶
Purpose: Instructions for transcribing and verifying data from block control documents and returns for the Business Master File Processing of the Exempt Organization Returns, using the Integrated Submission and Remittance Processing (ISRP) system.
Audience: Exempt Organization Data Transcribers at the Ogden Campus is the primary audience for this IRM.
Policy Owner: The Director, Tax Exempt/Government Entities (TE/GE), Business Systems Planning (BSP).
Program Owner: Submission Processing Programs and Oversight (SPP&O).
Primary Stakeholders: Exempt Organization Headquarters who rely on transcription of exempt organization returns.
Transcription operators may also need to refer to IRM 3.24.38, BMF General Instructions, for general procedures. If IRM 3.24.12 and IRM 3.24.38 conflict, IRM 3.24.12 takes precedence.
Due to substantial changes to the Form 990, batch and process Form 990 for 2007 and prior years, Form 990 for 2008 - 2013, and 2014 and subsequent years, under separate program codes. See IRM 3.24.12.3.
When making address updates, unless the filer specifically indicates room or suite, just the number should be entered.
Background¶
This section of the IRM provides general instructions for utilizing the ISRP system to transcribe data from variety of Exempt Organization Returns. See IRM 3.24.12.3
Roles and Responsibilities¶
The Director, Tax Exempt/Government Entities, Business Systems Planning (BSP) is the executive responsible for the Exempt Organization.
The Operations Manager is responsible for monitoring operational performance for their operation.
The Team Manager/Lead is responsible for performance monitoring and ensuring employees have the tools to perform their duties.
The Team Employees are responsible to follow the instructions contained in this IRM and maintain updated IRM procedures.
Program Management and Review¶
IRM 1.4.16, Accounts Management Guide for Managers, provides guidance for program management and review of programs assigned to Accounts Management.
Program Controls¶
The block control documents below are sources of transcribed control data:
Form 813, Document Register
Form 1332, Block and Selection Record
Form 3893, Re-entry Document Control
Terms and Acronyms¶
The following is a list of acronyms used in this IRM section, this IRM uses prompts for data entry defined in this table.
Acronyms
Definition
ABC
Alphanumeric Block Control
BMF
Business Master File
BOY
Beginning of Year
CAF
Centralized Authorization File
BSP
Business Systems Planning
CCC
Computer Condition Code
CD
Check Digit
CHNA
Community Health Needs Assessment
CI
Criminal Investigation
DLN
Document Locator Number
E-EIF
Enhanced-Entity Index File
EIN
Employer Identification Number
EOP
Entry Operator
EOY
End of Year
ERS
Error Resolution System
FAP
Financial Assistance Policy
FPG
Federal Poverty Guidelines
IDRS
Integrated Data Retrieval System
IUP
IRM Procedural Updates
IRI
Information Returns Intake
IRM
Internal Revenue Manual
IRS
Internal Revenue Service
ISRP
Integrated Submission and Remittance Processing System
KV
Key Verification
LB&I
Large Business and International Division
NC
Name Control
OFP
Organization Function Program
OAR
Operation Assistance Request
PTIN
Preparer Taxpayer Identification Numbers
RPC
Return Processing Code
RPS
Remittance Processing System
SB/SE
Small Business Self Employed Division
SCRS
Service Center Replacement System
SERP
Servicewide Electronic Research Program
SLAs
Service Level Agreements
SPP&O
Submission Processing Programs and Oversight
SSN
Social Security Number
TAS
Taxpayer Advocate Service
TBOR
Taxpayer Bill of Rights
TE/GE
Tax Exempt Government Entities Division
TIN
Taxpayer Identification Number
TS
Taxpayer Services
URL
Uniform Resource Locator
Taxpayer Advocate Service (TAS)¶
The Taxpayer Advocate Service (TAS) is an independent organization within the Internal Revenue Service (IRS), led by the National Taxpayer Advocate. Its job is to protect taxpayers’ rights by striving to ensure that every taxpayer is treated fairly and knows and understands their rights under the Taxpayer Bill of Rights (TBOR). TAS offers free help to taxpayers, including when taxpayers face financial difficulties due to an IRS problem, when they are unable to resolve tax problems they haven’t been able to resolve on their own, or when they need assistance to address an IRS system, process, or procedure that is not functioning as it should. TAS has at least one taxpayer advocate office located in every state, the District of Columbia, and Puerto Rico.
TAS uses Form 12412, Operations Assistance Request (OAR), to start the OAR process of referring a case to the Taxpayer Services (TS) Division, to affect the resolution of the taxpayer’s problem. For more information, refer to IRM 13.1.19, TAS Operations Assistance Request (OAR) Process.
Refer taxpayers to TAS when the contact meets TAS criteria or when Form 911, Request for Taxpayer Advocate Service Assistance (and Application for Taxpayer Assistance Order), is attached and steps cannot be taken to resolve the taxpayer’s issue the same day. See IRM 21.1.3.18, Taxpayer Advocate Service (TAS) Guidelines.
The definition of “same day resolution” is within 24 hours. the following two situations meet the definition of “same day resolution”:
The issue can be resolved within 24 hours.
IRS takes steps within 24 hours to resolve the taxpayer’s issue.
When making a TAS referral, use Form 911 and forward to TAS following your local procedures.
For more information see IRM 13.1.7, Taxpayer Advocate Service (TAS) Case Criteria, and 13.1.7.4, Exceptions to Taxpayer Advocate Service Criteria, for information on cases that TAS will no longer accept.
Service Level Agreements (SLAs)¶
The National Taxpayer Advocate reached agreements with the Commissioners or Chiefs of Taxpayer Services (TS) division, Small Business and Self Employed (SB/SE) Division, Tax Exempt and Government Entities (TE/GE), Criminal Investigation (CI), Independent Office Appeals, and Large Business and International (LB&I) that outline the procedures and responsibilities for the processing Taxpayer Advocate Service (TAS) casework when either the statutory or delegated authority to complete case transactions rests outside of TAS. These agreements are known as Service Level Agreements (SLAs).
SLAs are located in Service Level Agreements between the Tax Exempt & Government Entities Division and the Taxpayer Advocate Service.
Operations Assistance Requests (OARs)¶
TAS uses the Operation Assistance Request (OAR) process to refer cases when TAS lacks either the statutory or delegated authority to resolve a taxpayer's problem. TAS utilizes Form 12412, Operations Assistance Request to initiate the OAR process.
In cases requiring an OAR, TAS will complete Form 12412 and forward the case to the Operating Division Liaison via Form 3210. The Operating Division Liaison will review the case, assign it to the appropriate area, and monitor the case through it's conclusion.
Every effort must be made to expedite completion of OAR cases. Time frames for the assigned area to complete the case will be indicated on Form 12412.
If resolution of a taxpayer's case can't be completed by the requested time frame or by a negotiated extension date, the employee will immediately notify his or her manager.
The manager/employee will work with the TAS contact listed on Form 12412 to arrive at agreed upon time frames for follow-up based on the facts and circumstances of the particular case.
The manager/employee assigned the case will discuss the findings and recommendations on the final disposition of the case with the appropriate TAS contact. The TAS contact is responsible for communicating the final decision on the case to the taxpayer however this doesn't prohibit the manager/employee from also communicating that decision to the taxpayer.
If the TAS contact and the manager/employee assigned the case can't agree upon the resolution to the taxpayer's problem, the TAS employee will elevate this disagreement to the manager who will discuss it with the appropriate Operating Division manager. The manager/employee assigned the case will also elevate any disagreement to his or her manager.
For more information, please refer to: IRM 13, Taxpayer Advocate Service.
Forms/Program Numbers/Tax Class Doc. Codes¶
Form 990-EZ 2016 and subsequent will be batched under 13423 and 13424. In order for ISRP to pull up the correct screen for transcription, program code 13430 should be used.
Refer to the table below for forms, programs, and tax class doc codes.
Forms
Program Numbers (OFP)
Tax Class Document Codes
Form 990 (2008 - 2013), 425–431 & 259A-259H
13410
493
Form 990 (2016 - 2018)
13452
493
Form 990 (2014 and 2015)
13450
493
Form 990 (2007 and Prior)
13110
490
Form 990-EZ (2016 and subsequent
13430 (used for ISRP input only)
492
Form 990-EZ /527 (2016 and subsequent)
13424
492
Form 990-EZ (2007 and Prior)
13120
409
Form 990-PF
13131
491
Form 4720
13161
471
Form 990-EZ (2016 and subsequent)
13423
492
Form 990–EZ (2008 - 2015)
13420
492
Form 990-T
13141
393
Form 1041-A
13162
481
Form 5227
13190
483
Form 1120-POL
13170
320
Form 5578
13160
984
Form 5768
15502
977
Form 8872
16010
462
Form 990 (2019 and Subsequent)
13456
493
MUST ENTER Fields¶
Some fields require entry of data. These are MUST ENTER fields. Transcription Operation Sheets indicate MUST ENTER fields by the presence of stars (★★★★★★). See IRM 3.24.38 for procedures related to MUST ENTER fields.
Check Digit/Name Control¶
See the following subsections for entering either the Check Digit or Name Control.
Check Digit¶
Enter the Check Digit as follows:
If the EIN is unaltered on a preprinted label, enter the two alpha characters shown to the left of the EIN in the Check Digit (CD) field. You don't need to press
If the EIN is unaltered in the preprinted entity information of a CP Notice, enter the two alpha characters shown to the right of the EIN in the Check Digit (CD) field. You don't need to press
Note:¶
We moved the EIN and Check Digits for taxpayer privacy. On preprinted forms these items show up toward the title of the form. Enter the EIN and Check Digits. On NCOA labeled forms the EIN appears in this same area but the Check Digits aren’t present. Enter the EIN and then the Name Control.
The system fills the Name Control field with cent (¢) signs and positions the cursor on the EIN field. Enter the EIN.
If the Check Digit is invalid, the error message CHECK DIGIT ERROR appears. The cursor’s position is on the first digit of the EIN.
Check the Check Digit and EIN fields for errors.
If the Check Digit was entered incorrectly, press
If the EIN was entered incorrectly, correct the field using the normal procedures.
If both the Check Digit and EIN fields are correct, press
Name Control¶
In all other cases, press
Enter the four character Name Control indented, underlined or edited in the First Name Line area in the Name Control field (see IRM 3.24.38 for Name Control determination). You don't need to press
If less than four characters, enter those shown and press
If the Name Control is missing or illegible, enter one period, then press
Note:¶
Both fields can't contain entries; however, if both are entered, the system recognizes only the Check Digit and grays out the Name Control field.
Enhanced-Entity Index File¶
See IRM 3.24.38 for Enhanced-Entity Index File processing.
These procedures affect Forms Form 990, Form 990EZ, Form 990T, Form 990PF, Form 5227 and CP 411 – 414, 420 - 430, 259A – 259G.
Name Control Check Against Enhanced-Entity Index File¶
The following procedures affect Form 5578, Form 1041A, and Form 4720.
If a document is entered with a Name Control rather than a Check Digit, the system accesses the Enhanced-Entity Index File (E-EIF) to determine if the account is already established on the Master File. This procedure reduces the number of unpostables.
Note:¶
As soon as the EIN field is entered, the system accesses E-EIF. During this time, screen activity occurs and no entry can be made into the terminal. If the account is located, the Name Control entered automatically grayed out and the Check Digit appears in the Check Digit field on the screen. The EIN/Check Digit/Name Control fields bypass verification. If the account isn’t located, the Name Control remains on the screen as entered.
Specific Instructions for Entry of Data¶
This section provides specific instructions for entering data.
Required Sections & Section Verification¶
Required sections and section verification:
Form
Required Section
Required Section Verified
Other Section(s)
Other Section(s) Verified
Form 990 (2016 and Subsequent)
01, 02
100%
03 - 13
Yes - 100% if input
Form 990 (2014 and 2015
01, 02
100%
03 - 13
Yes - 100% if input
Form 990 (2008 and subsequent)
01, 02
100%
03–13
Yes - 100% if input
Form 990–EZ (2008 - 2013)
01, 02
100%
03–12
Yes - 100% if input
Form 990 & Form 990–EZ (2007 and Prior)
01, 02
100%
03–12
Yes - 100% if input
CP 411–414, 420–430 & 259A–259G and Organization Code "9" filers
01
100%
02
No
Form 990–PF
01–13
100% (Sections 01–07, 12 & 13)
N/A
Yes - if input and doesn't pass the zero balance test (Sections 08–11)
Form 990–T
01–04
Yes
07, 08, 15, 17, 20
Yes - if input *Section 20 is not verified
Form 1041–A
01
Yes
03
No
Form 1120–POL
01
Yes
02–05, 15, 20
Yes - 05 verified if input
Form 4720
01, 02
Yes
03
No
Form 5227
01–05
Yes
N/A
N/A
Form 5578
01
Yes
N/A
N/A
Form 5768
01
Yes
N/A
N/A
Form 8872
01
Yes
02, 03
Yes - if input
Foreign Address Procedures¶
ISRP enters the address fields on a foreign address. ISRP won't enter a CCC, "U" , or Action Code 650 to send the returns to (SCRS) or (ERS).
Refer to IRM 3.24.38.3.4.14.9 for correct procedures for entering foreign addresses.
Money Fields¶
All fields are DOLLARS AND CENTS unless otherwise specified.
A space and a dollar sign following the prompt (i.e. LN2 $) specifies the field is a dollars only field.
Since many reports generate from the information on these returns, take extreme care when entering the money amounts.
If the instruction calls for dollars only, don't enter cents (e.g., $400.00 entered as 400).
If the instruction calls for dollars and cents, be sure to enter the cents (e.g., $400 entered as 400.00).
Yes/No Boxes¶
For all Yes/No boxes, enter the digit edited to the right of the Line number.
If un-edited:
Enter "1" if the yes box is checked.
Enter "2" if the no box is checked.
Press
Percentage Fields¶
Input all percentage fields using up to three digits to the left of the decimal.
Example:¶
Program Service Business Codes¶
Enter all business codes exactly as shown except as follows:
If more than one code is present, enter the first code.
If the code is other than 4 or 6 digits, enter "0" (zero).
If there are any illegible digits, enter "0" (zero).
ISRP Transcription Operation Sheets¶
The following exhibits represent specific data entry procedures.
Block Header Data Entry Form 1332 for Original Input Documents, Form 3893 for Re-Entry…¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
SC Block Control
ABC
(auto)
The screen displays the ABC entered in the EOP Dialog box, as described in IRM 3.24.38.4.1.1. You can't change it.
(2)
Block DLN
DLN
Enter the first 11 digits as shown on:
Form 813, from the "Block DLN box."
Form 1332, in the "Block DLN box. "
Form 3893, in box 2.
The KV Operator verifies the DLN from the first document of the block.
(3)
Batch Number
BATCH
Enter the batch number as follows:
Form 813, 1332, from the Batch Control Number box.
Form 3893, from box 3.
If not present, secure the number from the Batch Transmittal Sheet.
(4)
Document Count
COUNT
Enter the document count as follows:
Form 813, 1332, the circled serial number. If a full block (100 documents) or if a number isn't circled, enter 100.
Form 3893, from box 4.
(5)
Pre-journalized Credit Amount
CR
Form 813, labeled "CR" or "Credit" .
Form 3893, box 5.
See narrative for amounts.
If neither "CR" or "DR" is labeled, enter as "CR"
(6)
Pre-journalized Debit Amount
DB
Form 813, labeled "DR" or "Debit" .
Form 3893, box 6.
See narrative for amounts.
(7)
Transaction Code
TRCODE
Press
Note:¶
For Form 5768, enter TC 460.
(8)
Transaction Date
TRDATE
Press
(9)
MFT Code
MFT
Enter the 2 digit code as follows:
Form 813, from the "Date" box.
Form 3893, from box 9.
Valid MFT's are: BMF - 05, 06, 15. IRA - (with TC 0) 29. If MFT is other than listed above, Press
(10)
Secondary Amount
SECAMT
Enter the bracketed amount as follows:
Form 813, in the "Total" box.
Form 3893, from box 10.
If zero, press
(11)
Source Code
SOURCE
If the control document is a Form 3893, enter from box 11 as follows:
R = "Reprocessable" box checked.
N = "Reinput of Unpostable" box checked.
4 = "SC Reinput" box checked.
None of the boxes checked, consult your supervisor who determines if a source code is required.
(12)
Year Digit
YEAR
If the control document is a Form 3893, enter the digit from the box 12 (current or otherwise).
This is a MUST ENTER field if the Source Code is "R" , "N" , or "4" .
(13)
Period Code
PRIOR YEAR
No entry.
(14)
RPS Indicator
RPS
Enter "2" if:
Form 813, 1332, "RPS" is edited or stamped in the upper center margin or "RRPS" is in the header of Form 1332.
Form 3893, box 13 is checked.
Form 990 - Section 01 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form.
If the system generated the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1 for procedures.
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4 for procedures.
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4 for procedures.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
For a CP 425–431 & 259A-259H, underlined to the right of the "Employer ID Number" .
See IRM 3.24.38 for standard rules.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
For a CP 425–431 & 259A-259H, edited in the area around the Tax Period.
See IRM 3.24.38 for special instructions.
(10)
In Care of Name Line
C/O NAME
Enter the in-care-of name, if shown.
Note:¶
Downstream processing generates the (%) sign.
(11)
Foreign Address
FGN ADD
Enter the foreign street address, if shown.
See IRM 3.24.38 for additional instructions.
(12)
Street Address
ADDR
Enter the street address from the address line.
If a "G" Condition Code is present, do NOT enter any of the address information, even if prompted to do so. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
See IRM 3.24.38 for specific instructions.
(13)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country code.
(14)
State
ST
Enter the standard state abbreviation from the city/state line.
If a Major City Code was entered, press
If a foreign address, enter a period (.).
See IRM 3.24.38.
(15)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
(16)
Group Code H(b)
BOXHB
Enter a "1" or "2" from the yes/no box from the entity area of the return, Line H(b).
For a CP425–431 & 259A-259H, press
(17)
Tax Exempt Status
BOXI
Enter the edited two digit code from the blank space of Box I.
(18)
Type of Organization
BOXK RT
Enter the edited code from the blank space of Box K.
For a CP 425–431 & 259A-259H always enter a "9" .
(19)
Computer Condition Codes
CCC
Enter the edited characters as shown on dotted portion of Lines 2–7b.
For a 420–431 & 259A-259H, enter the edited characters as shown in the center of the return.
If a Condition Code is illegible, enter a "#" in its place.
(20)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
If a "G" Condition Code is present and the return is non-remittance, end the document after this element.
If a CP 425–431 & 259A-259H, end the document after this element.
See IRM 3.24.38 for special instructions.
(21)
Preparation Code
PREP
Enter the edited code from the right of the preparer PTIN Line.
(22)
Preparer PTIN
PTIN
Enter the Preparer's PTIN.
(23)
Preparer's EIN
PEIN
Enter the preparer's EIN.
(24)
Preparer Telephone #
TEL#
Enter the preparer phone number.
If the Type of Organization is a "9" , and the 9 is underlined, don't end the document. Continue transcribing the return.
If Type of Organization is a "9" , and the "9" is NOT underlined, press
(25)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
(a) If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and the return is a remittance, Press
If the Type of Organization is "9" from Section 01 E–10 and the 9 is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is "9" , and the "9" is NOT underlined, press
Form 990 - Section 02, Form 5800 - Edit Sheet (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(3)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(4)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(5)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800, in MMDDYY format.
For special instructions, see IRM 3.24.38.
(6)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990 - Section 03 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return, ONLY if underlined in green.
(3)
IRI Codes
PG2TOP
Enter the edited digits from the top of page 2.
(4)
Undertake New Activities Y/N
L2
Enter a yes or no from the yes/no box from Part III, Line 2.
(5)
Make Significant Changes Y/N
L3
Enter a yes or no from the yes/no box from Part III, Line 3.
(6)
Exempt Purpose Code 1
L4A
Press Enter only. Don't transcribe a code.
(7)
Exempt Purpose Code 2
L4B
Press Enter only. Don't transcribe a code.
(8)
Exempt Purpose Code 3
L4C
Press Enter only. Don't transcribe a code.
(9)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
Note:¶
If a "D1" is edited and underlined, pick up as an alpha "D" and numeric "1" . Don't confuse with an alpha "D" and alpha "I" .
(10)
501(c)(3) or 4947(a)(1) Y/N
L1
Enter a yes or no from the yes/no box from Part IV, Line 1.
(11)
Required to Complete Sch B Y/N
L2
Enter a yes or no from the yes/no box from Part IV, Line 2.
(12)
Engage in Direct or Indirect Political Y/N
L3
Enter a yes or no from the yes/no box from Part IV, Line 3.
(13)
Engage in Lobbying Activities Y/N
L4
Enter a yes or no from the yes/no box from Part IV, Line 4.
(14)
Subject to Sec 6033(c) Notice
L5
Enter a yes or no from the yes/no box from Part IV, Line 5.
(15)
Maintain Donor Advised Y/N
L6
Enter a yes or no from the yes/no box from Part IV, Line 6.
(16)
Receive or Hold Conservation Y/N
L7
Enter a yes or no from the yes/no box from Part IV, Line 7.
(17)
Maintain Collections of Works of Art Y/N
L8
Enter a yes or no from the yes/no box from Part IV, Line 8.
(18)
Provide Credit Counseling Y/N
L9
Enter a yes or no from the yes/no box from Part IV, Line 9.
(19)
Hold Assets in Term/Permanent Y/N
L10
Enter a yes or no from the yes/no box from Part IV, Line 10.
(20)
Land, Buildings, Equipment
11A
Enter a yes or no from the yes/no box from Part IV, Line 11a.
(21)
Investments Other Securities
11B
Enter a yes or no from the yes/no box from Part IV, Line 11b.
(22)
Investments Program Related
11C
Enter a yes or no from the yes/no box from Part IV, Line 11c.
(23)
Other Assets
11D
Enter a yes or no from the yes/no box from Part IV, Line 11d.
(24)
Other Liabilities
11E
Enter a yes or no from the yes/no box from Part IV, Line 11e.
(25)
Separate or Consolidated Financial Statements
11F
Enter a yes or no from the yes/no box from Part IV, Line 11f.
(26)
Separate Independent Audited Financial
12A
Enter a yes or no from the yes/no box from Part IV, Line 12a.
(27)
Consolidated Independent Financial
12B
Enter a yes or no from the yes/no box from Part IV, Line 12b.
(28)
School Described in 170(b)(1)(A)(ii)
L13
Enter a yes or no from the yes/no box from Part IV, Line 13.
(29)
Maintain an Office, etc Outside U.S.
14A
Enter a yes or no from the yes/no box from Part IV, Line 14a.
(30)
Have Aggregate Revenues/Expenses
14B
Enter a yes or no from the yes/no box from Part IV, Line 14b.
(31)
Report > $5000 on Part IX Organizations
L15
Enter a yes or no from the yes/no box from Part IV, Line 15.
(32)
Report > $5000 on Part IX Individuals
L16
Enter a yes or no from the yes/no box from Part IV, Line 16.
(33)
Report > $15,000 on Part IX, Line 11e
L17
Enter a yes or no from the yes/no box from Part IV, Line 17.
(34)
Report > $15,000 on Part VIII, Line 1c/8a
L18
Enter a yes or no from the yes/no box from Part IV, Line 18.
(35)
Report > $15,000 on Part VIII, Line 9a
L19
Enter a yes or no from the yes/no box from Part IV, Line 19.
(36)
Operate Hospitals
20A
Enter a yes or no from the yes/no box from Part IV, Line 20a.
(37)
Attach Audited Financial Statements
20B
Enter a yes or no from the yes/no box from Part IV, Line 20b.
Form 990 - Section 04 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Report > $5000 on Part IX, Line 1
L21
Enter a yes or no from the yes/no box from Part IV, Line 21.
(3)
Report > $5000 on Part IX, Line 2
L22
Enter a yes or no from the yes/no box from Part IV, Line 22.
(4)
Answer Yes to Questions 3, 4, 5
L23
Enter a yes or no from the yes/no box from Part IV, Line 23.
(5)
Any Tax-Exempt Bond with Outstanding Principal
24A
Enter a yes or no from the yes/no box from Part IV, Line 24a.
(6)
Invest Any Proceeds
24B
Enter a yes or no from the yes/no box from Part IV, Line 24b.
(7)
Maintain an Escrow Account
24C
Enter a yes or no from the yes/box from Part IV, Line 24c.
(8)
Act as "On Behalf Of" Issuer
24D
Enter a yes or no from the yes/no box from Part IV, Line 24d.
(9)
501(c)(3) / 501(c)(4) Organizations
25A
Enter a yes or no from the yes/no box from Part IV, Line 25a.
(10)
Become Aware it Engaged in Excess
25B
Enter a yes or no from the yes/no box from Part IV, Line 25b.
(11)
Loan to/by Current/Former Officer
L26
Enter a yes or no from the yes/no box from Part IV, Line 26.
(12)
Provide Grant or Other Assistance
L27
Enter a yes or no from the yes/no box from Part IV, Line 27.
(13)
Business Transaction with Current or Former Officer
28A
Enter a yes or no from the yes/no box from Part IV, Line 28a.
(14)
Business Transaction with Family Member
28B
Enter a yes or no from the yes/no box from Part IV, Line 28b.
(15)
Business Transaction with Entity of Current/ Former Officer
28C
Enter a yes or no from the yes/no box from Part IV, Line 28c.
(16)
Receive or Accrue > $25,000 in Non-Cash
L29
Enter a yes or no from the yes/no box from Part IV, Line 29.
(17)
Receive or Accrue Contributions of Art
L30
Enter a yes or no from the yes/no box from Part IV, Line 30.
(18)
Liquidate, Terminate, Dissolve
L31
Enter a yes or no from the yes/no box from Part IV, Line 31.
(19)
Sell, Exchange, Dispose
L32
Enter a yes or no from the yes/no box from Part IV, Line 32.
(20)
Own 100% of an Entity
L33
Enter a yes or no from the yes/no box from Part IV, Line 33.
(21)
Related to Tax-Exempt / Taxable Entity
L34
Enter a yes or no from the yes/no box from Part IV, Line 34.
(22)
Controlled Entity Within 512(b)(13)
L35A
Enter a yes or no from the yes/no box from Part IV, Line 35a.
23
Receive Payment or Engage Transaction Within
L35B
Enter a yes or no from the yes/no box from Part IV, Line 35b.
(24)
Make Any Transfers
L36
Enter a yes or no from the yes/no box from Part IV, Line 36.
(25)
Conduct More than 5%
L37
Enter a yes or no from the yes/no box from Part IV, Line 37.
(26)
Complete Schedule O
L38
Enter a yes or no from the yes/no box from Part IV, Line 38.
Form 990 - Section 05 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part V Number of Forms/1096
PTVL1A
Enter the number shown on Part V, Line 1a.
(3)
Number of Forms W-2G
L1B
Enter the number shown on Part V, Line 1b.
(4)
Comply with Backup Withholding Rules
L1C
Enter a yes or no from the yes/no box from Part V, Line 1c.
(5)
Number of Employees / W-3
L2A
Enter the number shown on Part V, Line 2a.
(6)
File All Required Federal Employment Returns
L2B
Enter a yes or no from the yes/no box from Part V, Line 2b.
(7)
Unrelated Business Income > $1000
L3A
Enter a yes or no from the yes/box from Part V, Line 3a.
(8)
If Yes, Has Filed a 990-T
L3B
Enter a yes or no from the yes/no box from Part V, Line 3b.
(9)
Interest in or a Signature
L4A
Enter a yes or no from the yes/no box from Part V, Line 4a.
(10)
Party to a Prohibited Tax Shelter
L5A
Enter a yes or no from the yes/no box from Part V, Line 5a.
(11)
Taxable Party Notify Organization
L5B
Enter a yes or no from the yes/no box from Part V, Line 5b.
(12)
If Yes, Did Organization File 8886-T
L5C
Enter a yes or no from the yes/no box from Part V, Line 5c.
(13)
Annual Gross Receipts Normally >$100,000
L6A
Enter a yes or no from the yes/no box from Part V, Line 6a.
(14)
If Yes, Did Organization Include
L6B
Enter a yes or no from the yes/no box from Part V, Line 6b.
(15)
$75 Partly Contribution/Goods/Services
L7A
Enter a yes or no from the yes/no box from Part V, Line 7a.
(16)
If Yes, Did Organization Notify Donor
L7B
Enter a yes or no from the yes/no box from Part V, Line 7b.
(17)
Sell, Exchange, Otherwise Dispose
L7C
Enter a yes or no from the yes/no box from Part V, Line 7c.
(18)
Number of Forms 8282
L7D
Enter the number shown on Part V, Line 7d.
(19)
Receive Any Funds
L7E
Enter a yes or no from the yes/no box from Part V, Line 7e.
(20)
Pay Premiums
L7F
Enter a yes or no from the yes/no box from Part V, Line 7f.
(21)
Contributions of Qualified Intellectual Property
L7G
Enter a yes or no from the yes/no box from Part V, Line 7g.
(22)
Contributions of Cars, Boats, Airplanes
L7H
Enter a yes or no from the yes/no box from Part V, Line 7h.
(23)
Sponsoring Orgs, 509(a)(3) Excess Business Holdings
L8
Enter a yes or no from the yes/no box from Part V, Line 8.
(24)
Make Taxable Distributions Under 4966
L9A
Enter a yes or no from the yes/no box from Part V, Line 9a.
(25)
Make Distribution to Donor
L9B
Enter a yes or no from the yes/no box from Part V, Line 9b.
(26)
Initiation Fees/Capital Contributions
10A $
Enter the amount from Part V, Line 10a.
(27)
Gross Receipts for Public Use of Facilities
10B $
Enter the amount from Part V, Line 10b.
(28)
Gross Income/Members/Shareholders
11A $
Enter the amount from Part V, Line 11a.
(29)
Gross Income from Other Sources
11B $
Enter the amount from Part V, Line 11b.
(30)
4947(a)(1) Filing 990 in Lieu of 1041
12A
Enter a yes or no from the yes/no box from Part V, Line 12a.
(31)
Amount of Tax Exempt Interest
12B $
Enter the amount from Part V, Line 12b.
(32)
Licensed to Issue Qualified Health Plans
13A
Enter a yes or no from the yes/no box from Part V, Line 13a.
(33)
Aggregate Amount of Reserves to Maintain
13B $
Enter the amount from Part V, Line 13b.
(34)
Aggregate Amount of Reserves on Hand
13C $
Enter the amount from Part V, Line 13c.
(35)
Receive Payments for Indoor Tanning
14A
Enter a yes or no from the yes/no box from Part V, Line 14a.
(36)
Filed Form 720 to Report Payments
14B
Enter a yes or no from the yes/no box from Part V, Line 14b.
Form 990 - Section 06 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Voting Members of Governing Body
PG6L1A
Enter the number shown on Part VI, Section A, Line 1a.
(3)
Independent Voting Members
L1B
Enter the number shown on Part VI, Section A, Line 1b.
(4)
Officer, Director, Trustee Family/Relationship
L2
Enter a yes or no from the yes/no box from Part VI, Section A, Line 2.
(5)
Delegate Control Over Management
L3
Enter a yes or no from the yes/no box from Part VI, Section A, Line 3.
(6)
Make Significant Changes
L4
Enter a yes or no from the yes/no box from Part VI, Section A, Line 4.
(7)
Become Aware of Material Diversion
L5
Enter a yes or no from the yes/box from Part VI, Section A, Line 5.
(8)
Members of Stockholders
L6
Enter a yes or no from the yes/no box from Part VI, Section A, Line 6.
(9)
Members, Stockholders, Other Persons
7A
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7a.
(10)
Members Subject to Approval
7B
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7b.
(11)
Determining Compensation for CEO, Exec Director
15A
Enter a yes or no from the yes/no box from Part VI, Section B, Line 15a.
(12)
Total Reportable Compensation from Organization
PG8L1D(D) $
Enter the amount from Part VII, Section A, Line 1d, Column D.
(13)
Total Reportable Compensation from Related Organization
1D(E) $
Enter the amount from Part VII, Section A, Line 1d, Column E.
(14)
Total Compensation from Organization & Related Organizations
1D(F) $
Enter the amount from Part VII, Section A, Line 1d, Column F.
(15)
Total Individuals who Received > $100,000
SECTAL2
Enter the number shown on Part VII, Section A, Line 2.
(16)
Total Independent Contractors Received > $100,000
SECTBL2
Enter the number shown on Part VII, Section B, Line 2.
Form 990 - Section 07 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Contributions/ Gifts/Grants
PG9L1H $
Enter the amount from Part VIII, Line 1h, Column (A).
(3)
Program Service Business Code 2A
2ACODE
Enter the number shown on Part VIII, Line 2a.
(4)
2a Program Service Revenue Col. A
2A(A) $
Enter the amount from Part VIII, Line 2a, Column (A).
(5)
Program Service Business Code 2B
2BCODE
Enter the number shown on Part VIII, Line 2b.
(6)
2b Program Service Revenue Col. A
2B(A) $
Enter the amount from Part VIII, Line 2b, Column (A).
(7)
Program Service Business Code 2C
2CCODE
Enter the number shown on Part VIII, Line 2c.
(8)
2c Program Service Revenue Col. A
2C(A) $
Enter amount shown on Part VIII, Line 2c, Column (A).
(9)
Program Service Business Code 2D
2DCODE
Enter the number shown on Part VIII, Line 2d.
(10)
2d Program Service Revenue Col. A
2D(A) $
Enter amount shown on Part VIII, Line 2d, Column (A).
(11)
Program Service Business Code 2E
2ECODE
Enter the number shown on Part VIII, Line 2e.
(12)
2e Program Service Revenue Col. A
2E(A) $
Enter the amount from Part VIII, Line 2e, Column (A).
(13)
2f Program Service Revenue Col. A
2F(A) $
Enter the amount from Part VIII, Line 2f, Column (A).
(14)
2g Program Service Revenue Total Col. A
2GTOT $
Enter the amount from Part VIII, Line 2g, Column (A).
(15)
Investment Income Col. A
3(A) $
Enter the amount from Part VIII, Line 3, Column (A).
(16)
Tax-Exempt Bond Proceeds Col. A
4(A) $
Enter the amount from Part VIII, Line 4, Column (A).
(17)
Royalties Col. A
5(A) $
Enter the amount from Part VIII, Line 5, Column (A).
(18)
Gross Rents Real
6(A)I $
Enter the amount from Part VIII, Line 6a, Column (i).
(19)
Gross Rents Personal
6(A)II $
Enter the amount from Part VIII, Line 6a, Column (ii).
(20)
Rental Expenses Real
6(B)(I) $
Enter the amount from Part VIII, Line 6b, Column (i).
(21)
Rental Expenses Personal
6(B)(II) $
Enter the amount from Part VIII, Line 6b, Column (ii).
(22)
Rental Income/Loss Real
6C(I) $
Enter the amount from Part VIII, Line 6c, Column (i).
(23)
Rental Income/Loss Personal
6C(II) $
Enter the amount from Part VIII, Line 6c, Column (ii).
(24)
Net Rental Income/Loss Col. A
6D(A) $
Enter the amount from Part VIII, Line 6d, Column (A).
Form 990 - Section 08 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross Amount from Sales of Assets - Securities
PG9L7A(I) $
Enter the amount from Part VIII, Line 7a, Column (i).
(3)
Gross Amount from Sales of Assets - Other
7A(II) $
Enter the amount from Part VIII, Line 7a, Column (ii).
(4)
Cost or Other Basis/Sales - Securities
7B(I) $
Enter the amount from Part VIII, Line 7b, Column (i).
(5)
Cost or Other Basis/Sales - Other
7B(II) $
Enter the amount from Part VIII, Line 7b, Column (ii).
(6)
Gain/Loss - Securities
7C(I) $
Enter the amount from Part VIII, Line 7c, Column (i).
(7)
Gain/Loss - Other
7C(II) $
Enter the amount from Part VIII, Line 7c, Column (ii).
(8)
Net Gain/Loss Col. A
7D(A) $
Enter the amount from Part VIII, Line 7d, Column (A).
(9)
Gross Income from Fundraising
8A $
Enter the amount from Part VIII, Line 8a.
(10)
Less Direct Expenses 8b
8B $
Enter the amount from Part VIII, Line 8b.
(11)
Net Income/Loss from Fundraising Col. A
8C(A) $
Enter the amount from Part VIII, Line 8c, Column (A).
(12)
Gross Income from Gaming
9A $
Enter the amount from Part VIII, Line 9a.
(13)
Less Direct Expenses 9b
9B $
Enter the amount from Part VIII, Line 9b.
(14)
Net Income/Loss from Gaming
9C(A) $
Enter the amount from Part VIII, Line 9c, Column (A).
(15)
Gross Sales of Inventory
10A $
Enter the amount from Part VIII, Line 10a.
(16)
Less Cost of Goods Sold
10B $
Enter the amount from Part VIII, Line 10b.
(17)
Net Income/Loss from Sales Col. A
10C(A) $
Enter the amount from Part VIII, Line 10c, Column (A).
(18)
Misc. Revenue Business Code 11a
11ACODE
Enter the number shown on Part VIII, Line 11a.
(19)
Misc. Revenue Total (A) Col. A
11A(A) $
Enter the amount from Part VIII, Line 11a, Column (A).
(20)
Misc. Revenue Business Code 11b
11BCODE
Enter the number shown on Part VIII, Line 11b.
(21)
Misc. Revenue Total 11B(A) Col. A
11B(A) $
Enter the amount from Part VIII, Line 11b, Column (A).
(22)
Misc. Revenue Business Code 11c
11CCODE
Enter the number shown on Part VIII, Line 11c.
(23)
Misc. Revenue Total 11C(A) Col. A
11C(A) $
Enter the amount from Part VIII, Line 11c, Column (A).
(24)
Misc. Revenue Total 11D(A) Col. A
11D(A) $
Enter the amount from Part VIII, Line 11d, Column (A).
(25)
Misc. Revenue Total 11E Col. A
11ETOT $
Enter the amount from Part VIII, Line 11e, Column (A).
(26)
Total Revenue 12(A) Col. A
12(A) $
Enter the amount from Part VIII, Line 12, Column (A).
Form 990 - Section 09 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross to Government / Organizations in U.S.
PG10L1(A) $
Enter the amount from Part IX, Line 1, Column (A).
(3)
Grants / Other Assistance in U.S.
L2(A) $
Enter the amount from Part IX, Line 2, Column (A).
(4)
Grants / Other Assistance Outside U.S.
L3(A) $
Enter the amount from Part IX, Line 3, Column (A).
(5)
Benefits Paid to / for Members
L4(A) $
Enter the amount from Part IX, Line 4, Column (A).
(6)
Compensation of Current Officers / Directors
L5(A) $
Enter the amount from Part IX, Line 5, Column (A).
(7)
Compensation to Disqualified Persons
L6(A) $
Enter the amount from Part IX, Line 6, Column (A).
(8)
Other Salaries / Wages
L7(A) $
Enter the amount from Part IX, Line 7, Column (A).
(9)
Pension Plan Contributions
L8(A) $
Enter the amount from Part IX, Line 8, Column (A).
(10)
Other Employee Benefits
L9(A) $
Enter the amount from Part IX, Line 9, Column (A).
(11)
Payroll Taxes
10(A) $
Enter the amount from Part IX, Line 10, Column (A).
(12)
Fees for Services / Management
11A(A) $
Enter the amount from Part IX, Line 11a, Column (A).
(13)
Fees for Services / Legal
11B(A) $
Enter the amount from Part IX, Line 11b, Column (A).
(14)
Fees for Services / Accounting
11C(A) $
Enter the amount from Part IX, Line 11c, Column (A).
(15)
Fees for Services / Lobbyists
11D(A) $
Enter the amount from Part IX, Line 11d, Column (A).
(16)
Fees for Services / Professional Fundraising
11E(A) $
Enter the amount from Part IX, Line 11e, Column(A).
(17)
Fees for Services / Investment Management
11F(A) $
Enter the amount from Part IX, Line 11f, Column (A).
(18)
Fees for Services / Other
11G(A) $
Enter the amount from shown on Part IX, Line 11g, Column (A).
(19)
Advertising / Promotion
12(A) $
Enter the amount from Part IX, Line 12, Column (A).
(20)
Office Expenses
13(A) $
Enter the amount from on Part IX, Line 13, Column (A).
(21)
Information Technology
14(A) $
Enter the amount from Part IX, Line 14, Column (A).
(22)
Royalties
15(A) $
Enter the amount from Part IX, Line 15, Column (A).
(23)
Occupancy
16(A) $
Enter the amount from Part IX, Line 16, Column (A).
(24)
Travel
17(A) $
Enter the amount from Part IX, Line 17, Column (A).
(25)
Payments of Travel / Entertainment
18(A) $
Enter the amount from Part IX, Line 18, Column (A).
(26)
Conferences, Conventions / Meetings
19(A) $
Enter the amount from Part IX, Line 19, Column (A).
(27)
Interest
20(A) $
Enter the amount from Part IX, Line 20, Column (A).
(28)
Payments to Affiliates
21(A) $
Enter the amount from Part IX, Line 21, Column (A).
(29)
Depreciation / Depletion
22(A) $
Enter the amount from Part IX, Line 22, Column (A).
(30)
Insurance
23(A) $
Enter the amount from Part IX, Line 23, Column (A).
(31)
Other Expenses a
24A(A) $
Enter the amount from Part IX, Line 24a, Column (A).
(32)
Other Expenses b
24B(A) $
Enter the amount from Part IX, Line 24b, Column (A).
(33)
Other Expenses c
24C(A) $
Enter the amount from Part IX, Line 24c, Column (A).
(34)
Other Expenses d
24D(A) $
Enter the amount from Part IX, Line 24d, Column (A).
(35)
Other Expenses e
24E(A) $
Enter the amount from Part IX, Line 24e, Column (A).
(36)
NA
24F $
Enter only.
(37)
Total Functional Expenses
25(A) $
Enter the amount from Part IX, Line 25, Column (A).
Form 990 - Section 10 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash EOY
PG11L1(B) $
Enter the amount from Part X, Line 1, Column (B).
(3)
Savings / Temporary Investments EOY
L2(B) $
Enter the amount from Part X, Line 2, Column (B).
(4)
Pledges / Grants Receivable EOY
L3(B) $
Enter the amount from Part X, Line 3, Column (B).
(5)
Accounts Receivable EOY
L4(B) $
Enter the amount from Part X, Line 4, Column (B).
(6)
Receivables from Current / Former EOY
L5(B) $
Enter the amount from Part X, Line 5, Column (B).
(7)
Receivables from Disqualified Persons EOY
L6(B) $
Enter the amount from Part X, Line 6, Column (B).
(8)
Notes / Loans Receivable EOY
L7(B) $
Enter the amount from Part X, Line 7, Column (B).
(9)
Inventories for Sale EOY
L8(B) $
Enter the amount from Part X, Line 8, Column (B).
(10)
Prepaid Expenses EOY
L9(B) $
Enter the amount from Part X, Line 9, Column (B).
(11)
Land / Buildings Less Accumulated EOY
10C(B) $
Enter the amount from Part X, Line 10c, Column (B).
(12)
Investments Publicly Traded Securities EOY
11(B) $
Enter the amount from Part X, Line 11, Column (B).
(13)
Investments Other Securities EOY
12(B) $
Enter the amount from Part X, Line 12, Column (B).
(14)
Investments Program Related EOY
13(B) $
Enter the amount from Part X, Line 13, Column (B).
(15)
Intangible Assets EOY
14(B) $
Enter the amount from Part X, Line 14, Column (B).
(16)
Other Assets EOY
15(B) $
Enter the amount from Part X, Line 15, Column(B).
(17)
Total Assets BOY
16(A) $
Enter the amount from Part X, Line 16, Column (A).
(18)
Total Assets EOY
16(B) $
Enter the amount from shown on Part X, Line 16, Column (B).
(19)
Accounts Payable EOY
17(B) $
Enter the amount from Part X, Line 17, Column (B).
(20)
Grants Payable EOY
18(B) $
Enter the amount from on Part X, Line 18, Column (B).
(21)
Deferred Revenue EOY
19(B) $
Enter the amount from Part X, Line 19, Column (B).
(22)
Tax-Exempt Bond Liabilities EOY
20(B) $
Enter the amount from Part X, Line 20, Column (B).
(23)
Escrow Liability EOY
21(B) $
Enter the amount from Part X, Line 21, Column (B).
(24)
Payable to Current / Former Officers EOY
22(B) $
Enter the amount from Part X, Line 22, Column (B).
(25)
Secured Mortgages / Notes EOY
23(B) $
Enter the amount from Part X, Line 23, Column (B).
(26)
Unsecured Notes / Loans EOY
24(B) $
Enter the amount from Part X, Line 24, Column (B).
(27)
Other Liabilities EOY
25(B) $
Enter the amount from Part X, Line 25, Column (B).
(28)
Total Liabilities BOY
26(A) $
Enter the amount from Part X, Line 26, Column (A).
(29)
Total Liabilities EOY
26(B) $
Enter the amount from Part X, Line 26, Column (B).
(30)
Unrestricted Net Assets EOY
27(B) $
Enter the amount from Part X, Line 27, Column (B).
(31)
Temporarily Restricted Net Assets EOY
28(B) $
Enter the amount from Part X, Line 28, Column (B).
(32)
Permanently Restricted Net Assets EOY
29(B) $
Enter the amount from Part X, Line 29, Column (B).
(33)
Capital Stock / Trust EOY
30(B) $
Enter the amount from Part X, Line 30, Column (B).
(34)
Paid-In / Capital Surplus EOY
31(B) $
Enter the amount from Part X, Line 31, Column (B).
(35)
Retained Earnings, Endowment EOY
32(B) $
Enter the amount from Part X, Line 32, Column (B).
(36)
Total Net Assets or Fund Balances BOY
33(A) $
Enter the amount from Part X, Line 33, Column (A).
(37)
Total Net Assets or Fund Balances EOY
33(B) $
Enter the amount from Part X, Line 33, Column (B).
(38)
Total Liabilities / Net Assets Fund Balances EOY
34(B) $
Enter the amount from Part X, Line 34, Column (B).
Form 990 - Section 11, Schedule A (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Type of Organization
L11
Enter one of the following:
1 = Type I, 2 = Type II, 3 = Type III – Functionally integrated
4 = Type III – Non-functionally integrated Blank
If more than one box is checked, enter the corresponding number for the first box checked.
(4)
Type I, II or III Supporting Organization
11E
Enter a "1" if the box is checked on Schedule A, Part I, Line 11e.
(5)
Number of Supported Organizations
11F
Enter the number from Line 11f.
(6)
EIN A
11G(II)A
Enter the EIN in Part I, Line 11g, Row A, Column (ii).
(7)
Type of Org A
11G(III)A
Enter the type of organization in Part I, Line 11g, Row A, Column (iii).
(8)
Listed in Governing Doc A
11G(IV)A
Enter 1 for yes and 2 for no from checkbox in Part I, Line 11g, Row A, Column (iv).
(9)
Amount of Support A
11G(V) A $
Enter the amount on Part I, Line 11g, Row A, Column (v).
(10)
EIN B
11G(II)B
Enter the EIN in Part I, Line 11g, Row B, Column (ii).
(11)
Type of Org B
11G(III)B
Enter the type of organization in Part I, Line 11g, Row B, Column (iii).
(12)
Listed in Governing Doc B
11G(IV)B
Enter 1 for yes and 2 for no from checkbox in Part I, Line 11g, Row B, Column (iv).
(13)
Amount of Support B
11G(V)B $
Enter the amount Part I, Line 11g, Row B, Column (v).
(14)
EIN C
11G(II)C
Enter the EIN in Part I, Line 11g, Row C, Column (ii).
(15)
Type of Org C
11G(III)C
Enter the type of organization in Part I, Line 11g, Row C, Column (iii).
(16)
Listed in Governing Doc C
11G(IV)C
Enter 1 for yes and 2 for no from checkbox in Part I, Line 11g, Row C, Column (iv).
(17)
Amount of Support C
11G(V)C $
Enter the amount on Part I, Line 11g, Row C, Column (v).
(18)
EIN D
11G(II)D
Enter the EIN in Part I, Line 11g, Row D, Column (ii).
(19)
Type of Org D
11G(III)D
Enter the type of organization in Part I, Line 11g, Row D, Column (iii).
(20)
Listed in Governing Doc D
11G(IV)D
Enter 1 for yes and 2 for no from checkbox in Part I, Line 11g, Row D, Column (iv).
(21)
Amount of Support D
11G(V)D $
Enter the amount on Part I, Line 11g, Row D, Column (v).
(22)
EIN E
11G(II)E
Enter the EIN in Part I, Line 11g, Row E, Column (ii).
(23)
Type of Org E
11G(III)E
Enter the type of organization in Part I, Line 11g, Row E, Column (iii).
(24)
Listed in Governing Doc E
11G(IV)E
Enter 1 for yes and 2 for no from checkbox in Part I, Line 11g, Row E, Column (iv).
(25)
Amount of Support E
11G(V)E $
Enter the amount on Part I, Line 11g, Row E, Column (v).
(26)
Total Number of Organizations
11G(I)TOT
Enter the number from Schedule A, Part I, Line 11h, Column (i), Total Line.
(27)
Total
G(V)TOT $
Enter the amount on Part I, Line 11g, Total, Column (v).
(28)
Filling Field
N/A
Blank field generates on output.
(29)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(30)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(31)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(32)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(33)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(34)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(35)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(36)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(37)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(38)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(39)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(40)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(41)
First 5 Years Checkbox
13CKBX
Enter a "1" if the box on Schedule A, Part II, Line 13 is checked.
(42)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 16a is checked.
(43)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 16b is checked.
(44)
10% Facts & Circumstances Current
17ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 17a is checked.
(45)
10% Facts & Circumstances Prior
17BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 17b is checked.
(46)
Private Foundation Checkbox
18CKBX
Enter a "1" if the box on Schedule A, Part II, Line 18 is checked.
Form 990 - Section 12, Schedule A (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter a "1" if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter a "1" if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter a "1" if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter a "1" if the box on Schedule A, Part III, Line 20 is checked.
(23)
Part IV Section A Data Present Indicator
PTIVA
Enter a 1 if data is present in Part IV, Section A.
(24)
Part IV Section B Data Present Indicator
PTIVB
Enter a 1 if data is present in Part IV, Section B.
(25)
Part IV Section C Data Present Indicator
PTIVC
Enter a 1 if data is present in Part IV, Section C.
(26)
Part IV Section D Data Present Indicator
PTIVD
Enter a 1 if data is present in Part IV, Section D.
(27)
Part IV Section E Data Present Indicator
PTIVE
Enter a 1 if data is present in Part IV, Section E.
(28)
Part V Data Present Indicator
PTV
Enter a 1 if data is present in Part V.
Form 990 - Section 13, Schedules C & D (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHC1AL2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Total Number at EOY
SCHDL1(A)
Enter the number shown on Schedule D, Part I, Line 1, Column (a).
(4)
Contributions To
L2(A) $
Enter the amount from Schedule D, Part I, Line 2, Column (a).
(5)
Grants From
L3(A) $
Enter the amount from Schedule D, Part I, Line 3, Column (a).
(6)
Aggregate Value
L4(A) $
Enter the amount from Schedule D, Part I, Line 4, Column (a).
(7)
Inform All Donors Checkbox
L5
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 5.
(8)
Inform All Grantees Checkbox
L6
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 6.
Form 990 - Section 31, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Financial Assistance
L1A
Enter the following from the checkbox Schedule H, Part I, Line 1a:
1 = yes
2 = no.
(3)
Written Policy
L1B
Enter the following from the checkbox Schedule H, Part I, Line 1b:
1 = yes
2 = no.
(4)
Best Describes
L2
Enter the following:
1 = Applied Uniformly to all.
2 = Applied Uniformly to most.
3 = Generally tailored.
(5)
FPG Used
L3A
Enter the following from the checkbox Schedule H, Part I, Line 3a:
1 = yes
2 = no.
(6)
FPG%
L3A%
Enter the following from Schedule H, Part I, Line 3a percent:
1 = 100%
2 = 150%
3 = 200%
4 = Other.
(7)
FPG Discounted Care
L3B
Enter the following from the checkbox Schedule H, Part I, Line 3b:
1 = yes
2 = no.
(8)
FPG Discounted Care %
L3B%
Enter the percent that is next to the marked box from Schedule H, Part I, Line 3b percent:
1 = 200%
2 = 250%
3 = 300%
4 = 350%
5 = 400%
6 = Other
If more than one box is checked, enter the number for the largest percent.
(9)
Applied to Largest Number of Patients
L4
Enter the following from the checkbox Schedule H, Part I, Line 4:
1 = yes
2 = no.
(10)
Budget Amounts for Free or Discounted
L5A
Enter the following from the checkbox Schedule H, Part I, Line 5a:
1 = yes
2 = no.
(11)
Exceed Budget Amount
L5B
Enter the following from the checkbox Schedule H, Part I, Line 5b:
1 = yes
2 = no.
(12)
Unable to Provide Free or Discounted Care
L5C
Enter the following from the checkbox Schedule H, Part I, Line 5c:
1 = yes
2 = no.
(13)
Prepare A Community Benefit Report
L6A
Enter the following from the checkbox Schedule H, Part I, Line 6a:
1 = yes
2 = no.
(14)
Available to Public
L6B
Enter the following from the checkbox Schedule H, Part I, Line 6b:
1 = yes
2 = no.
(15)
Financial Assistance C
L7AC $
Enter the amount from Schedule H, Part I, Line 7a, Column (c).
(16)
Financial D
L7AD $
Enter the amount from Schedule H, Part I, Line 7a, Column (d).
(17)
Financial Assistance at Cost Net Community
SCHH 7A(E) $
Enter the amount from Schedule H, Part I, Line 7a, Column (e).
(18)
Financial Assistance at Cost Percent
7A(F)
Enter the percent from Schedule H, Part I, Line 7a, Column (f).
(19)
Medicaid C
L7BC $
Enter the amount from Schedule H, Part I, Line 7b, Column (c).
(20)
Medicaid D
L7BD $
Enter the amount from Schedule H, Part I, Line 7b, Column (d).
(21)
Unreimbursed Medicaid Net Community
7B(E) $
Enter the amount from Schedule H, Part I, Line 7b, Column (e).
(22)
Unreimbursed Medicaid Percent
7B(F)
Enter the percent from Schedule H, Part I, Line 7b, Column (f).
(23)
Cost of Other Means Tested C
L7CC $
Enter the amount from Schedule H, Part I, Line 7c, Column (c).
(24)
Cost of Other Means Tested D
L7DC $
Enter the amount from Schedule H, Part I, Line 7c, Column (d).
(25)
Unreimbursed Costs - Other Net Community
7C(E) $
Enter the amount from Schedule H, Part I, Line 7c, Column (e).
(26)
Unreimbursed Costs - Other Percent
7C(F)
Enter the percent from Schedule H, Part I, Line 7c, Column (f).
(27)
Financial Assistance Total C
7DC $
Enter the amount from Schedule H, Part I, Line 7d, Column (c).
(28)
Financial Assistance Total D
7DD $
Enter the amount from Schedule H, Part I, Line 7d, Column (d).
(29)
Total Financial Assistance Net Community
7D(E) $
Enter the amount from Schedule H, Part I, Line 7d, Column (e).
(30)
Total Financial Assistance Percent
7D(F)
Enter the percent from Schedule H, Part I, Line 7d, Column (f).
Form 990 - Section 32, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Community Health Improvement C
7EC $
Enter the amount from Schedule H, Part I, Line 7e, Column (c).
(3)
Community Health Improvement D
7ED $
Enter the amount from Schedule H, Part I, Line 7e, Column (d).
(4)
Community Health Improvement E
7EE $
Enter the amount from Schedule H, Part I, Line 7e, Column (e).
(5)
Community Health Improvement Percent
7EF%
Enter the percent from Schedule H, Part I, Line 7e, Column (f).
(6)
Health Professions C
7FC $
Enter the amount from Schedule H, Part I, Line 7f, Column (c).
(7)
Health Professions D
7FD $
Enter the amount from Schedule H, Part I, Line 7f, Column (d).
(8)
Health Professions E
7FE $
Enter the amount from Schedule H, Part I, Line 7f, Column (e).
(9)
Health Professions Percent
7FF%
Enter the percent from Schedule H, Part I, Line 7f, Column (f).
(10)
Subsidized Health Services C
7GC $
Enter the amount from Schedule H, Part I, Line 7g, Column (c).
(11)
Subsidized Health Services D
7GD $
Enter the amount from Schedule H, Part I, Line 7g, Column (d).
(12)
Subsidized Health Services E
7GE $
Enter the amount from Schedule H, Part I, Line 7g, Column (e).
(13)
Subsidized Health Services Percent
7GF%
Enter the percent from Schedule H, Part I, Line 7g, Column (f).
(14)
Research C
7HC $
Enter the amount from Schedule H, Part I, Line 7h, Column (c).
(15)
Research D
7HD $
Enter the amount from Schedule H, Part I, Line 7h, Column (d).
(16)
Research E
7HE $
Enter the amount from Schedule H, Part I, Line 7h, Column (e).
(17)
Research F Percent
7HF%
Enter the percent from Schedule H, Part I, Line 7h, Column (f).
(18)
Cash & Contributions C
7IC $
Enter the amount from Schedule H, Part I, Line 7i, Column (c).
(19)
Cash & Contributions D
7ID $
Enter the amount from Schedule H, Part I, Line 7i, Column (d).
(20)
Cash & Contributions E
7IE $
Enter the amount from Schedule H, Part I, Line 7i, Column (e).
(21)
Cash & Contributions %
7IF%
Enter the percent from Schedule H, Part I, Line 7i, Column (f).
(22)
Total Other Benefits C
7JC $
Enter the amount from Schedule H, Part I, Line 7j, Column (c).
(23)
Total Other Benefits D
7JD $
Enter the amount from Schedule H, Part I, Line 7j, Column (d).
(24)
Total Other Benefits E
7JE $
Enter the amount from Schedule H, Part I, Line 7j, Column (e).
(25)
Total Other Benefits Percent
7JF%
Enter the percent from Schedule H, Part I, Line 7j, Column (f).
(26)
Total C
7KC $
Enter the amount from Schedule H, Part I, Line 7k, Column (c).
(27)
Total D
7KD $
Enter the amount from Schedule H, Part I, Line 7k, Column (d).
(28)
Total E
7KE $
Enter the amount from Schedule H, Part I, Line 7k, Column (e).
(29)
Total Percent
7KF%
Enter the percent from Schedule H, Part I, Line 7k, Column (f).
Form 990 - Section 33, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Net Community
PII10E $
Enter the amount from Schedule H, Part II, Line 10, Column (e).
(3)
Total Percent of Expense
10F%
Enter the percent from Schedule H, Part II, Line 10 Column (f).
(4)
Report Bad Debt Expense
PT3L1
Enter a yes or no from the yes/no box on Sch H, Part III, Line 1.
(5)
Bad Debt Expense Amount
L2 $
Enter the amount from Schedule H, Part III, Line 2.
(6)
Estimated Bad Debt Expense Amount
L3 $
Enter the amount from Schedule H, Part III, Line 3.
(7)
Revenue from Medicare
L5 $
Enter the amount from Schedule H, Part III, Line 5.
(8)
Medicare Allowable Costs
L6 $
Enter the amount from Schedule H, Part III, Line 6.
(9)
Medicare Surplus or Shortfall
L7 $
Enter the amount from Schedule H, Part III, Line 7.
(10)
Costing Methodology or Source Code
L8CD
Enter the edited code from the right of the boxes from Schedule H, Part III, Line 8.
(11)
Written Debt Collection Policy
L9A
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9a.
(12)
Collection Policy Contain Provision
L9B
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9b.
(13)
Part IV Code
PIVCD
Enter the edited digit from Schedule H, Part IV, right margin.
(14)
Part V How Many Hospital Facilities Did Organization Operate
SECATOP
Enter the number shown in the Hospital Facilities area in the top left portion of Schedule H, Part V, Section A.
(15)
Part V Section C Indicator Code
SECCRM
Enter the indicator code from Schedule H, Part V, Section C, right margin.
(16)
Part V How Many Non-Hospital Facilities Did Organization Operate
SECCTOP
Enter the number from the non-hospital health care benefits line.
(17)
Part V Section D Indicator Code
SECTDRM
Enter the edited code from Schedule H, Part V, Section D, right margin.
Form 990 - Section 34, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 35, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a" 1" if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
Filling Field
N/A
Generate blank field on output.
(19)
Other
16I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16i is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Filling Field
N/A
Generate blank field on output.
(24)
Actions That Require Legal or Judicial Process
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(25)
Other Similar Actions
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(26)
None of These Actions
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
Form 990 - Section 36, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Filling Field
N/A
Generate blank field on output.
(6)
Actions That Require Legal or Judicial Process
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(7)
Other Similar Actions
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(8)
Notified Financial Assistance Upon Admission
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Notified Financial Assistance Prior to Discharge
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Notified Financial Assistance in Bills
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Documented Its Determination
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Negotiated Commercial Insurance Rate
22A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Average of the Three Lowest Negotiated Commercial Insurance Rates
22B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Medicare Rate
22C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Other
22D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 37, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 38, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a" 1" if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
Filling Field
N/A
Generate blank field on output.
(19)
Other
16I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16i is checked.
(20)
Separate Billing and Collections Billing
17
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17 is checked.
(21)
Reporting to Credit Agency
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Filling Field
N/A
Generate a blank field on output.
(24)
Actions That Require Legal or Judicial Process
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(25)
Other Similar Actions
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(26)
None of These Actions
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
Form 990 - Section 39, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Filling Field
N/A
Generate blank field on output.
(6)
Actions That Require Legal or Judicial Process
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(7)
Other Similar Actions
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(8)
Notified Financial Assistance Upon Admission
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Notified Financial Assistance Prior to Discharge
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Notified Financial Assistance in Bills
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Documented Its Determination
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Negotiated Commercial Insurance Rate
22A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Average of the Three Lowest Negotiated Commercial Insurance Rates
22B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Medicare Rate
22C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Other
22D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 40, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 41, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a" 1" if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
Filling Field
N/A
Generate blank field on output.
(19)
Other
16I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16i is checked.
(20)
Separate Billing and Collections Billing
17
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17 is checked.
(21)
Reporting to Credit Agency
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Filling Field
N/A
Generate blank field on output.
(24)
Actions That Require Legal or Judicial Process
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(25)
Other Similar Actions
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(26)
None of These Actions
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
Form 990 - Section 42, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Filling Field
N/A
Generate blank field on output.
(6)
Actions That Require Legal or Judicial Process
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(7)
Other Similar Actions
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(8)
Notified Financial Assistance Upon Admission
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Notified Financial Assistance Prior to Discharge
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Notified Financial Assistance in Bills
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Documented Its Determination
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Negotiated Commercial Insurance Rate
22A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Average of the Three Lowest Negotiated Commercial Insurance Rates
22B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Medicare Rate
22C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Other
22D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 43, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 44, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a" 1" if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
Filling Field
N/A
Generate blank field on output.
(19)
Other
16I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16i is checked.
(20)
Separate Billing and Collections Billing
17
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17 is checked.
(21)
Reporting to Credit Agency
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Filling Field
N/A
Generate blank field on output.
(24)
Actions That Require Legal or Judicial Process
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(25)
Other Similar Actions
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(26)
None of These Actions
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
Form 990 - Section 45, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Filling Field
N/A
Generate blank field on output.
(6)
Actions That Require Legal or Judicial Process
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(7)
Other Similar Actions
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(8)
Notified Financial Assistance Upon Admission
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Notified Financial Assistance Prior to Discharge
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Notified Financial Assistance in Bills
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Documented Its Determination
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Negotiated Commercial Insurance Rate
22A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Average of the Three Lowest Negotiated Commercial Insurance Rates
22B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Medicare Rate
22C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Other
22D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 46, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 47, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a" 1" if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
Filling Field
N/A
Generate a blank field on output.
(19)
Other
16I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16i is checked.
(20)
Separate Billing and Collections Billing
17
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17 is checked.
(21)
Reporting to Credit Agency
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Filling Field
N/A
Generate blank field on output.
(24)
Actions That Require Legal or Judicial Process
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(25)
Other Similar Actions
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(26)
None of These Actions
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
Form 990 - Section 48, Schedule H (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Filling Field
N/A
Generate blank field on output.
(6)
Actions That Require Legal or Judicial Process
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(7)
Other Similar Actions
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(8)
Notified Financial Assistance Upon Admission
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Notified Financial Assistance Prior to Discharge
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Notified Financial Assistance in Bills
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Documented Its Determination
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Negotiated Commercial Insurance Rate
22A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Average of the Three Lowest Negotiated Commercial Insurance Rates
22B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Medicare Rate
22C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Other
22D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 49, Schedules L and R (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Excess Benefit Transactions
PT1 RTMAR
Enter the edited digit from the right margin of Schedule L, Part 1.
(3)
Approved by Board or Committee
PT2 RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
(4)
Interest, Annuities, Royalties, Yes/No Box
SCHR PT51A
Enter a yes or a no from the yes/no box from Schedule R, Part V, Line 1a.
Form 990 - Section 01 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form.
If the system generated the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4 for procedures.
(3a)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4 for procedures.
(4)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
For a CP 425–431 & 259A-259H, underlined to the right of the Employer ID Number.
See standard rules in IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(5)
Address Check
ADDRESS CHECK?
Enter Y or N as appropriate.
(6)
Street Key
STREET KEY
See IRM 3.24.38
(7)
ZIP Key
ZIP KEY
See IRM 3.24.38
(8)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under title of form.
If not edited or underlined, press
For a CP 425–431 & 259A-259H, edited in the area around the Tax Period.
See IRM 3.24.38 for special instructions.
(9)
In Care of Name Line
C/O NAME
Enter the in-care-of name, if shown.
Note:¶
Downstream processing generates the (%) sign.
(10)
Foreign Address
FGN ADD
Enter the foreign street address, if shown.
See IRM 3.24.38 for additional instructions.
(11)
Street Address
ADDR
Enter the street address from the address line.
If a "G" Condition Code is present, do NOT enter any of the address information, even if prompted to do so. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
See IRM 3.24.38 for specific instructions.
(12)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country code.
(13)
State
ST
Enter the standard state abbreviation from the city/state line
If a Major City Code was entered, press
If a foreign address, enter a period (.).
See IRM 3.24.38.
(14)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
(15)
Group Code H(b)
BOXHB
Enter a "1" or "2" from the yes/no box from the entity area of the return, Line H(b).
For a CP425–431 & 259A-259H, press
(16)
Tax Exempt Status
BOXI
Enter the edited two digit code from the blank space of Box I.
(17)
Type of Organization
BOXK RT
Enter the edited code from the blank space of Box K.
For a CP 425–431 & 259A-259H always enter a "9" .
(18)
Computer Condition Codes
CCC
Enter the edited characters as shown on dotted portion of Lines 2–7b.
For a 420–431 & 259A-259H, enter the edited characters as shown in the center of the return.
If a Condition Code is illegible, enter a # in its place.
(19)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
If a "G" Condition Code is present and the return is non-remittance, end the document after this element.
If a CP 425–431 & 259A-259H, end the document after this element.
See IRM 3.24.38 for special instructions.
(20)
Preparation Code
PREP
Enter the edited code from the right of the preparer PTIN Line.
(21)
Preparer PTIN
PTIN
Enter the Preparer's PTIN.
(22)
Preparer's EIN
PEIN
Enter the preparer's EIN.
(23)
Preparer Telephone #
TEL#
Enter the preparer phone number.
If the Type of Organization is a "9" , and the "9" is underlined, don't end the document. Continue transcribing the return.
If Type of Organization is a "9" , and the "9" is NOT underlined, press
(24)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the 600 series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the 600 series and the return is a remittance, press
If a "G" Condition Code is present and the return is a remittance, Press
If the Type of Organization is 9 from Section 01 E–10 and the " 9" is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is 9, and the 9 is NOT underlined, press
Form 990 - Section 02 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(3)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(4)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(5)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800, in MMDDYY format.
For special instructions, see IRM 3.24.38.
(6)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990 - Section 03 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return, ONLY if underlined in green.
(3)
IRI Codes
PG2TOP
Enter the edited digits from the top of page 2.
(4)
Undertake New Activities Y/N
L2
Enter a yes or no from the yes/no box from Part III, Line 2.
(5)
Make Significant Changes Y/N
L3
Enter a yes or no from the yes/no box from Part III, Line 3.
(6)
Exempt Purpose Code 1
L4A
Press Enter only. Don't transcribe a code.
(7)
Exempt Purpose Code 2
L4B
Press Enter only. Don't transcribe a code.
(8)
Exempt Purpose Code 3
L4C
Press Enter only. Don't transcribe a code.
(9)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
Note:¶
If a "D1" is edited and underlined, pick up as an alpha "D" and numeric "1" . Don't confuse with an alpha "D" and alpha "I" .
(10)
501(c)(3) or 4947(a)(1) Y/N
L1
Enter a yes or no from the yes/no box from Part IV, Line 1.
(11)
Required to Complete Sch B Y/N
L2
Enter a yes or no from the yes/no box from Part IV, Line 2.
(12)
Engage in Direct or Indirect Political Y/N
L3
Enter a yes or no from the yes/no box from Part IV, Line 3.
(13)
Engage in Lobbying Activities Y/N
L4
Enter a yes or no from the yes/no box from Part IV, Line 4.
(14)
Subject to Sec 6033(c) Notice
L5
Enter a yes or no from the yes/no box from Part IV, Line 5.
(15)
Maintain Donor Advised Y/N
L6
Enter a yes or no from the yes/no box from Part IV, Line 6.
(16)
Receive or Hold Conservation Y/N
L7
Enter a yes or no from the yes/no box from Part IV, Line 7.
(17)
Maintain Collections of Works of Art Y/N
L8
Enter a yes or no from the yes/no box from Part IV, Line 8.
(18)
Provide Credit Counseling Y/N
L9
Enter a yes or no from the yes/no box from Part IV, Line 9.
(19)
Hold Assets in Term/Permanent Y/N
L10
Enter a yes or no from the yes/no box from Part IV, Line 10.
(20)
Land, Buildings, Equipment
11A
Enter a yes or no from the yes/no box from Part IV, Line 11a.
(21)
Investments Other Securities
11B
Enter a yes or no from the yes/no box from Part IV, Line 11b.
(22)
Investments Program Related
11C
Enter a yes or no from the yes/no box from Part IV, Line 11c.
(23)
Other Assets
11D
Enter a yes or no from the yes/no box from Part IV, Line 11d.
(24)
Other Liabilities
11E
Enter a yes or no from the yes/no box from Part IV, Line 11e.
(25)
Separate or Consolidated Financial Statements
11F
Enter a yes or no from the yes/no box from Part IV, Line 11f.
(26)
Separate Independent Audited Financial
12A
Enter a yes or no from the yes/no box from Part IV, Line 12a.
(27)
Consolidated Independent Financial
12B
Enter a yes or no from the yes/no box from Part IV, Line 12b.
(28)
School Described in 170(b)(1)(A)(ii)
L13
Enter a yes or no from the yes/no box from Part IV, Line 13.
(29)
Maintain an Office, etc Outside U.S.
14A
Enter a yes or no from the yes/no box from Part IV, Line 14a.
(30)
Have Aggregate Revenues/Expenses
14B
Enter a yes or no from the yes/no box from Part IV, Line 14b.
(31)
Report > $5000 on Part IX Organizations
L15
Enter a yes or no from the yes/no box from Part IV, Line 15.
(32)
Report > $5000 on Part IX Individuals
L16
Enter a yes or no from the yes/no box from Part IV, Line 16.
(33)
Report > $15,000 on Part IX, Line 11e
L17
Enter a yes or no from the yes/no box from Part IV, Line 17.
(34)
Report > $15,000 on Part VIII, Line 1c/8a
L18
Enter a yes or no from the yes/no box from Part IV, Line 18.
(35)
Report > $15,000 on Part VIII, Line 9a
L19
Enter a yes or no from the yes/no box from Part IV, Line 19.
(36)
Operate Hospitals
20A
Enter a yes or no from the yes/no box from Part IV, Line 20a.
(37)
Attach Audited Financial Statements
20B
Enter a yes or no from the yes/no box from Part IV, Line 20b.
Form 990 - Section 04 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Report > $5000 on Part IX, Line 1
L21
Enter a yes or no from the yes/no box from Part IV, Line 21.
(3)
Report > $5000 on Part IX, Line 2
L22
Enter a yes or no from the yes/no box from Part IV, Line 22.
(4)
Answer Yes to Questions 3, 4, 5
L23
Enter a yes or no from the yes/no box from Part IV, Line 23.
(5)
Any Tax-Exempt Bond with Outstanding Principal
24A
Enter a yes or no from the yes/no box from Part IV, Line 24a.
(6)
Invest Any Proceeds
24B
Enter a yes or no from the yes/no box from Part IV, Line 24b.
(7)
Maintain an Escrow Account
24C
Enter a yes or no from the yes/box from Part IV, Line 24c.
(8)
Act as On Behalf Of Issuer
24D
Enter a yes or no from the yes/no box from Part IV, Line 24d.
(9)
501(c)(3) / 501(c)(4) Organizations
25A
Enter a yes or no from the yes/no box from Part IV, Line 25a.
(10)
Become Aware it Engaged in Excess
25B
Enter a yes or no from the yes/no box from Part IV, Line 25b.
(11)
Loan to/by Current/Former Officer
L26
Enter a yes or no from the yes/no box from Part IV, Line 26.
(12)
Provide Grant or Other Assistance
L27
Enter a yes or no from the yes/no box from Part IV, Line 27.
(13)
Business Transaction with Current or Former Officer
28A
Enter a yes or no from the yes/no box from Part IV, Line 28a.
(14)
Business Transaction with Family Member
28B
Enter a yes or no from the yes/no box from Part IV, Line 28b.
(15)
Business Transaction with Entity of Current/ Former Officer
28C
Enter a yes or no from the yes/no box from Part IV, Line 28c.
(16)
Receive or Accrue > $25,000 in Non-Cash
L29
Enter a yes or no from the yes/no box from Part IV, Line 29.
(17)
Receive or Accrue Contributions of Art
L30
Enter a yes or no from the yes/no box from Part IV, Line 30.
(18)
Liquidate, Terminate, Dissolve
L31
Enter a yes or no from the yes/no box from Part IV, Line 31.
(19)
Sell, Exchange, Dispose
L32
Enter a yes or no from the yes/no box from Part IV, Line 32.
(20)
Own 100% of an Entity
L33
Enter a yes or no from the yes/no box from Part IV, Line 33.
(21)
Related to Tax-Exempt / Taxable Entity
L34
Enter a yes or no from the yes/no box from Part IV, Line 34.
(22)
Controlled Entity Within 512(b)(13)
35A
Enter a yes or no from the yes/no box from Part IV, Line 35a.
(23)
Receive Payment or Engage Transaction Within
35B
Enter a yes or no from the yes/no box from Part IV, Line 35b.
(24)
Make Any Transfers
L36
Enter a yes or no from the yes/no box from Part IV, Line 36.
(25)
Conduct More than 5%
L37
Enter a yes or no from the yes/no box from Part IV, Line 37.
(26)
Complete Schedule O
L38
Enter a yes or no from the yes/no box from Part IV, Line 38.
Form 990 - Section 05 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part V Number of Forms/1096
PTVL1A
Enter the number shown on Part V, Line 1a.
(3)
Number of Forms W-2G
L1B
Enter the number shown on Part V, Line 1b.
(4)
Comply with Backup Withholding Rules
L1C
Enter a yes or no from the yes/no box from Part V, Line 1c.
(5)
Number of Employees / W-3
L2A
Enter the number shown on Part V, Line 2a.
(6)
File All Required Federal Employment Returns
L2B
Enter a yes or no from the yes/no box from Part V, Line 2b.
(7)
Unrelated Business Income > $1000
L3A
Enter a yes or no from the yes/box from Part V, Line 3a.
(8)
If Yes, Has Filed a 990-T
L3B
Enter a yes or no from the yes/no box from Part V, Line 3b.
(9)
Interest in or a Signature
L4A
Enter a yes or no from the yes/no box from Part V, Line 4a.
(10)
Party to a Prohibited Tax Shelter
L5A
Enter a yes or no from the yes/no box from Part V, Line 5a.
(11)
Taxable Party Notify Organization
L5B
Enter a yes or no from the yes/no box from Part V, Line 5b.
(12)
If Yes, Did Organization File 8886-T
L5C
Enter a yes or no from the yes/no box from Part V, Line 5c.
(13)
Annual Gross Receipts Normally >$100,000
L6A
Enter a yes or no from the yes/no box from Part V, Line 6a.
(14)
If Yes, Did Organization Include
L6B
Enter a yes or no from the yes/no box from Part V, Line 6b.
(15)
$75 Partly Contribution/Goods/Services
L7A
Enter a yes or no from the yes/no box from Part V, Line 7a.
(16)
If Yes, Did Organization Notify Donor
L7B
Enter a yes or no from the yes/no box from Part V, Line 7b.
(17)
Sell, Exchange, Otherwise Dispose
L7C
Enter a yes or no from the yes/no box from Part V, Line 7c.
(18)
Number of Forms 8282
L7D
Enter the number shown on Part V, Line 7d.
(19)
Receive Any Funds
L7E
Enter a yes or no from the yes/no box from Part V, Line 7e.
(20)
Pay Premiums
L7F
Enter a yes or no from the yes/no box from Part V, Line 7f.
(21)
Contributions of Qualified Intellectual Property
L7G
Enter a yes or no from the yes/no box from Part V, Line 7g.
(22)
Contributions of Cars, Boats, Airplanes
L7H
Enter a yes or no from the yes/no box from Part V, Line 7h.
(23)
Sponsoring Orgs, 509(a)(3) Excess Business Holdings
L8
Enter a yes or no from the yes/no box from Part V, Line 8.
(24)
Make Taxable Distributions Under 4966
L9A
Enter a yes or no from the yes/no box from Part V, Line 9a.
(25)
Make Distribution to Donor
L9B
Enter a yes or no from the yes/no box from Part V, Line 9b.
(26)
Initiation Fees/Capital Contributions
10A $
Enter the amount from Part V, Line 10a.
(27)
Gross Receipts for Public Use of Facilities
10B $
Enter the amount from Part V, Line 10b.
(28)
Gross Income/Members/Shareholders
11A $
Enter the amount from Part V, Line 11a.
(29)
Gross Income from Other Sources
11B $
Enter the amount from Part V, Line 11b.
(30)
4947(a)(1) Filing 990 in Lieu of 1041
12A
Enter a yes or no from the yes/no box from Part V, Line 12a.
(31)
Amount of Tax Exempt Interest
12B $
Enter the amount from Part V, Line 12b.
(32)
Licensed to Issue Qualified Health Plans
13A
Enter a yes or no from the yes/no box from Part V, Line 13a.
(33)
Aggregate Amount of Reserves to Maintain
13B $
Enter the amount from Part V, Line 13b.
(34)
Aggregate Amount of Reserves on Hand
13C $
Enter the amount from Part V, Line 13c.
(35)
Receive Payments for Indoor Tanning
14A
Enter a yes or no from the yes/no box from Part V, Line 14a.
(36)
Filed Form 720 to Report Payments
14B
Enter a yes or no from the yes/no box from Part V, Line 14b.
Form 990 - Section 06 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Voting Members of Governing Body
PG6L1A
Enter the number shown on Part VI, Section A, Line 1a.
(3)
Independent Voting Members
L1B
Enter the number shown on Part VI, Section A, Line 1b.
(4)
Officer, Director, Trustee Family/Relationship
L2
Enter a yes or no from the yes/no box from Part VI, Section A, Line 2.
(5)
Delegate Control Over Management
L3
Enter a yes or no from the yes/no box from Part VI, Section A, Line 3.
(6)
Make Significant Changes
L4
Enter a yes or no from the yes/no box from Part VI, Section A, Line 4.
(7)
Become Aware of Material Diversion
L5
Enter a yes or no from the yes/box from Part VI, Section A, Line 5.
(8)
Members of Stockholders
L6
Enter a yes or no from the yes/no box from Part VI, Section A, Line 6.
(9)
Members, Stockholders, Other Persons
7A
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7a.
(10)
Members Subject to Approval
7B
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7b.
(11)
Determining Compensation for CEO, Exec Director
15A
Enter a yes or no from the yes/no box from Part VI, Section B, Line 15a.
(12)
Total Reportable Compensation from Organization
PG8L1D(D) $
Enter the amount from Part VII, Section A, Line 1d, Column D.
(13)
Total Reportable Compensation from Related Organization
1D(E) $
Enter the amount from Part VII, Section A, Line 1d, Column E.
(14)
Total Compensation from Organization & Related Organizations
1D(F) $
Enter the amount from Part VII, Section A, Line 1d, Column F.
(15)
Total Individuals who Received > $100,000
SECTAL2
Enter the number shown on Part VII, Section A, Line 2.
(16)
Total Independent Contractors Received > $100,000
SECTBL2
Enter the number shown on Part VII, Section B, Line 2.
Form 990 - Section 07 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Contributions/ Gifts/Grants
PG9L1H $
Enter the amount from Part VIII, Line 1h, Column (A).
(3)
Program Service Business Code 2A
2ACODE
Enter the number shown on Part VIII, Line 2a.
(4)
2a Program Service Revenue Col. A
2A(A) $
Enter the amount from Part VIII, Line 2a, Column (A).
(5)
Program Service Business Code 2B
2BCODE
Enter the number shown on Part VIII, Line 2b.
(6)
2b Program Service Revenue Col. A
2B(A) $
Enter the amount from Part VIII, Line 2b, Column (A).
(7)
Program Service Business Code 2C
2CCODE
Enter the number shown on Part VIII, Line 2c.
(8)
2c Program Service Revenue Col. A
2C(A) $
Enter amount shown on Part VIII, Line 2c, Column (A).
(9)
Program Service Business Code 2D
2DCODE
Enter the number shown on Part VIII, Line 2d.
(10)
2d Program Service Revenue Col. A
2D(A) $
Enter amount shown on Part VIII, Line 2d, Column (A).
(11)
Program Service Business Code 2E
2ECODE
Enter the number shown on Part VIII, Line 2e.
(12)
2e Program Service Revenue Col. A
2E(A) $
Enter the amount from Part VIII, Line 2e, Column (A).
(13)
2f Program Service Revenue Col. A
2F(A) $
Enter the amount from Part VIII, Line 2f, Column (A).
(14)
2g Program Service Revenue Total Col. A
2GTOT $
Enter the amount from Part VIII, Line 2g, Column (A).
(15)
Investment Income Col. A
3(A) $
Enter the amount from Part VIII, Line 3, Column (A).
(16)
Tax-Exempt Bond Proceeds Col. A
4(A) $
Enter the amount from Part VIII, Line 4, Column (A).
(17)
Royalties Col. A
5(A) $
Enter the amount from Part VIII, Line 5, Column (A).
(18)
Gross Rents Real
6(A)I $
Enter the amount from Part VIII, Line 6a, Column (i).
(19)
Gross Rents Personal
6(A)II $
Enter the amount from Part VIII, Line 6a, Column (ii).
(20)
Rental Expenses Real
6(B)(I) $
Enter the amount from Part VIII, Line 6b, Column (i).
(21)
Rental Expenses Personal
6(B)(II) $
Enter the amount from Part VIII, Line 6b, Column (ii).
(22)
Rental Income/Loss Real
6C(I) $
Enter the amount from Part VIII, Line 6c, Column (i).
(23)
Rental Income/Loss Personal
6C(II) $
Enter the amount from Part VIII, Line 6c, Column (ii).
(24)
Net Rental Income/Loss Col. A
6D(A) $
Enter the amount from Part VIII, Line 6d, Column (A).
Form 990 - Section 08 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross Amount from Sales of Assets - Securities
PG9L7A(I) $
Enter the amount from Part VIII, Line 7a, Column (i).
(3)
Gross Amount from Sales of Assets - Other
7A(II) $
Enter the amount from Part VIII, Line 7a, Column (ii).
(4)
Cost or Other Basis/Sales - Securities
7B(I) $
Enter the amount from Part VIII, Line 7b, Column (i).
(5)
Cost or Other Basis/Sales - Other
7B(II) $
Enter the amount from Part VIII, Line 7b, Column (ii).
(6)
Gain/Loss - Securities
7C(I) $
Enter the amount from Part VIII, Line 7c, Column (i).
(7)
Gain/Loss - Other
7C(II) $
Enter the amount from Part VIII, Line 7c, Column (ii).
(8)
Net Gain/Loss Col. A
7D(A) $
Enter the amount from Part VIII, Line 7d, Column (A).
(9)
Gross Income from Fundraising
8A $
Enter the amount from Part VIII, Line 8a.
(10)
Less Direct Expenses 8b
8B $
Enter the amount from Part VIII, Line 8b.
(11)
Net Income/Loss from Fundraising Col. A
8C(A) $
Enter the amount from Part VIII, Line 8c, Column (A).
(12)
Gross Income from Gaming
9A $
Enter the amount from Part VIII, Line 9a.
(13)
Less Direct Expenses 9b
9B $
Enter the amount from Part VIII, Line 9b.
(14)
Net Income/Loss from Gaming
9C(A) $
Enter the amount from Part VIII, Line 9c, Column (A).
(15)
Gross Sales of Inventory
10A $
Enter the amount from Part VIII, Line 10a.
(16)
Less Cost of Goods Sold
10B $
Enter the amount from Part VIII, Line 10b.
(17)
Net Income/Loss from Sales Col. A
10C(A) $
Enter the amount from Part VIII, Line 10c, Column (A).
(18)
Misc. Revenue Business Code 11a
11ACODE
Enter the number shown on Part VIII, Line 11a.
(19)
Misc. Revenue Total (A) Col. A
11A(A) $
Enter the amount from Part VIII, Line 11a, Column (A).
(20)
Misc. Revenue Business Code 11b
11BCODE
Enter the number shown on Part VIII, Line 11b.
(21)
Misc. Revenue Total 11B(A) Col. A
11B(A) $
Enter the amount from Part VIII, Line 11b, Column (A).
(22)
Misc. Revenue Business Code 11c
11CCODE
Enter the number shown on Part VIII, Line 11c.
(23)
Misc. Revenue Total 11C(A) Col. A
11C(A) $
Enter the amount from Part VIII, Line 11c, Column (A).
(24)
Misc. Revenue Total 11D(A) Col. A
11D(A) $
Enter the amount from Part VIII, Line 11d, Column (A).
(25)
Misc. Revenue Total 11E Col. A
11ETOT $
Enter the amount from Part VIII, Line 11e, Column (A).
(26)
Total Revenue 12(A) Col. A
12(A) $
Enter the amount from Part VIII, Line 12, Column (A).
Form 990 - Section 09 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross to Government / Organizations in U.S.
PG10L1(A) $
Enter the amount from Part IX, Line 1, Column (A).
(3)
Grants / Other Assistance in U.S.
L2(A) $
Enter the amount from Part IX, Line 2, Column (A).
(4)
Grants / Other Assistance Outside U.S.
L3(A) $
Enter the amount from Part IX, Line 3, Column (A).
(5)
Benefits Paid to / for Members
L4(A) $
Enter the amount from Part IX, Line 4, Column (A).
(6)
Compensation of Current Officers / Directors
L5(A) $
Enter the amount from Part IX, Line 5, Column (A).
(7)
Compensation to Disqualified Persons
L6(A) $
Enter the amount from Part IX, Line 6, Column (A).
(8)
Other Salaries / Wages
L7(A) $
Enter the amount from Part IX, Line 7, Column (A).
(9)
Pension Plan Contributions
L8(A) $
Enter the amount from Part IX, Line 8, Column (A).
(10)
Other Employee Benefits
L9(A) $
Enter the amount from Part IX, Line 9, Column (A).
(11)
Payroll Taxes
10(A) $
Enter the amount from Part IX, Line 10, Column (A).
(12)
Fees for Services / Management
11A(A) $
Enter the amount from Part IX, Line 11a, Column (A).
(13)
Fees for Services / Legal
11B(A) $
Enter the amount from Part IX, Line 11b, Column (A).
(14)
Fees for Services / Accounting
11C(A) $
Enter the amount from Part IX, Line 11c, Column (A).
(15)
Fees for Services / Lobbyists
11D(A) $
Enter the amount from Part IX, Line 11d, Column (A).
(16)
Fees for Services / Professional Fundraising
11E(A) $
Enter the amount from Part IX, Line 11e, Column(A).
(17)
Fees for Services / Investment Management
11F(A) $
Enter the amount from Part IX, Line 11f, Column (A).
(18)
Fees for Services / Other
11G(A) $
Enter the amount from shown on Part IX, Line 11g, Column (A).
(19)
Advertising / Promotion
12(A) $
Enter the amount from Part IX, Line 12, Column (A).
(20)
Office Expenses
13(A) $
Enter the amount from on Part IX, Line 13, Column (A).
(21)
Information Technology
14(A) $
Enter the amount from Part IX, Line 14, Column (A).
(22)
Royalties
15(A) $
Enter the amount from Part IX, Line 15, Column (A).
(23)
Occupancy
16(A) $
Enter the amount from Part IX, Line 16, Column (A).
(24)
Travel
17(A) $
Enter the amount from Part IX, Line 17, Column (A).
(25)
Payments of Travel / Entertainment
18(A) $
Enter the amount from Part IX, Line 18, Column (A).
(26)
Conferences, Conventions / Meetings
19(A) $
Enter the amount from Part IX, Line 19, Column (A).
(27)
Interest
20(A) $
Enter the amount from Part IX, Line 20, Column (A).
(28)
Payments to Affiliates
21(A) $
Enter the amount from Part IX, Line 21, Column (A).
(29)
Depreciation / Depletion
22(A) $
Enter the amount from Part IX, Line 22, Column (A).
(30)
Insurance
23(A) $
Enter the amount from Part IX, Line 23, Column (A).
(31)
Other Expenses a
24A(A) $
Enter the amount from Part IX, Line 24a, Column (A).
(32)
Other Expenses b
24B(A) $
Enter the amount from Part IX, Line 24b, Column (A).
(33)
Other Expenses c
24C(A) $
Enter the amount from Part IX, Line 24c, Column (A).
(34)
Other Expenses d
24D(A) $
Enter the amount from Part IX, Line 24d, Column (A).
(35)
Other Expenses e
24E(A) $
Enter the amount from Part IX, Line 24e, Column (A).
(36)
NA
24F$
Enter only.
(37)
Total Functional Expenses
25(A) $
Enter the amount from Part IX, Line 25, Column (A).
Form 990 - Section 10 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash EOY
PG11L1(B) $
Enter the amount from Part X, Line 1, Column (B).
(3)
Savings / Temporary Investments EOY
L2(B) $
Enter the amount from Part X, Line 2, Column (B).
(4)
Pledges / Grants Receivable EOY
L3(B) $
Enter the amount from Part X, Line 3, Column (B).
(5)
Accounts Receivable EOY
L4(B) $
Enter the amount from Part X, Line 4, Column (B).
(6)
Receivables from Current / Former EOY
L5(B) $
Enter the amount from Part X, Line 5, Column (B).
(7)
Receivables from Disqualified Persons EOY
L6(B) $
Enter the amount from Part X, Line 6, Column (B).
(8)
Notes / Loans Receivable EOY
L7(B) $
Enter the amount from Part X, Line 7, Column (B).
(9)
Inventories for Sale EOY
L8(B) $
Enter the amount from Part X, Line 8, Column (B).
(10)
Prepaid Expenses EOY
L9(B) $
Enter the amount from Part X, Line 9, Column (B).
(11)
Land / Buildings Less Accumulated EOY
10C(B) $
Enter the amount from Part X, Line 10c, Column (B).
(12)
Investments Publicly Traded Securities EOY
11(B) $
Enter the amount from Part X, Line 11, Column (B).
(13)
Investments Other Securities EOY
12(B) $
Enter the amount from Part X, Line 12, Column (B).
(14)
Investments Program Related EOY
13(B) $
Enter the amount from Part X, Line 13, Column (B).
(15)
Intangible Assets EOY
14(B) $
Enter the amount from Part X, Line 14, Column (B).
(16)
Other Assets EOY
15(B) $
Enter the amount from Part X, Line 15, Column(B).
(17)
Total Assets BOY
16(A) $
Enter the amount from Part X, Line 16, Column (A).
(18)
Total Assets EOY
16(B) $
Enter the amount from shown on Part X, Line 16, Column (B).
(19)
Accounts Payable EOY
17(B) $
Enter the amount from Part X, Line 17, Column (B).
(20)
Grants Payable EOY
18(B) $
Enter the amount from on Part X, Line 18, Column (B).
(21)
Deferred Revenue EOY
19(B) $
Enter the amount from Part X, Line 19, Column (B).
(22)
Tax-Exempt Bond Liabilities EOY
20(B) $
Enter the amount from Part X, Line 20, Column (B).
(23)
Escrow Liability EOY
21(B) $
Enter the amount from Part X, Line 21, Column (B).
(24)
Payable to Current / Former Officers EOY
22(B) $
Enter the amount from Part X, Line 22, Column (B).
(25)
Secured Mortgages / Notes EOY
23(B) $
Enter the amount from Part X, Line 23, Column (B).
(26)
Unsecured Notes / Loans EOY
24(B) $
Enter the amount from Part X, Line 24, Column (B).
(27)
Other Liabilities EOY
25(B) $
Enter the amount from Part X, Line 25, Column (B).
(28)
Total Liabilities BOY
26(A) $
Enter the amount from Part X, Line 26, Column (A).
(29)
Total Liabilities EOY
26(B) $
Enter the amount from Part X, Line 26, Column (B).
(30)
Unrestricted Net Assets EOY
27(B) $
Enter the amount from Part X, Line 27, Column (B).
(31)
Temporarily Restricted Net Assets EOY
28(B) $
Enter the amount from Part X, Line 28, Column (B).
(32)
Permanently Restricted Net Assets EOY
29(B) $
Enter the amount from Part X, Line 29, Column (B).
(33)
Capital Stock / Trust EOY
30(B) $
Enter the amount from Part X, Line 30, Column (B).
(34)
Paid-In / Capital Surplus EOY
31(B) $
Enter the amount from Part X, Line 31, Column (B).
(35)
Retained Earnings, Endowment EOY
32(B) $
Enter the amount from Part X, Line 32, Column (B).
(36)
Total Net Assets or Fund Balances BOY
33(A) $
Enter the amount from Part X, Line 33, Column (A).
(37)
Total Net Assets or Fund Balances EOY
33(B) $
Enter the amount from Part X, Line 33, Column (B).
(38)
Total Liabilities / Net Assets Fund Balances EOY
34(B) $
Enter the amount from Part X, Line 34, Column (B).
Form 990 - Section 11, Schedule A (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Type of Organization
L11
Enter one of the following from Line 12:
1 = Type I
2 = Type II
3 = Type III – Functionally integrated
4 = Type III – Non-functionally integrated Blank
If more than one box is checked, enter the corresponding number for the first box checked.
(4)
Type I, II or III Supporting Organization
11E
Enter a "1" if the box is checked on Schedule A, Part I, Line 12e.
(5)
Number of Supported Organizations
11F
Enter the number from Line 12f.
(6)
EIN A
12G(II)A
Enter the EIN in Part I, Line 11g, Row A, Column (ii).
(7)
Type of Org A
12G(III)A
Enter the type of organization in Part I, Line 11g, Row A, Column (iii).
If more than one digit, enter the first digit only.
(8)
Listed in Governing Doc A
12G(IV)A
Enter "1" for yes and "2" for no from checkbox in Part I, Line 12g, Row A, Column (iv).
(9)
Amount of Support A
12G(V) A$
Enter the amount on Part I, Line 12g, Row A, Column (v).
(10)
EIN B
12G(II)B
Enter the EIN in Part I, Line 12g, Row B, Column (ii).
(11)
Type of Org B
12G(III)B
Enter the type of organization in Part I, Line 12g, Row B, Column (iii).
(12)
Listed in Governing Doc B
12G(IV)B
Enter "1" for yes and "2" for no from checkbox in Part I, Line 12g, Row B, Column (iv).
(13)
Amount of Support B
12G(V)B $
Enter the amount Part I, Line 12g, Row B, Column (v).
(14)
EIN C
12G(II)C
Enter the EIN in Part I, Line 12g, Row C, Column (ii).
(15)
Type of Org C
12G(III)C
Enter the type of organization in Part I, Line 12g, Row C, Column (iii).
(16)
Listed in Governing Doc C
12G(IV)C
Enter "1 " for yes and "2" for no from checkbox in Part I, Line 12g, Row C, Column (iv).
(17)
Amount of Support C
12G(V)C $
Enter the amount on Part I, Line 12g, Row C, Column (v).
(18)
EIN D
12G(II)D
Enter the EIN in Part I, Line 12g, Row D, Column (ii).
(19)
Type of Org D
12G(III)D
Enter the type of organization in Part I, Line 12g, Row D, Column (iii).
(20)
Listed in Governing Doc D
12G(IV)D
Enter "1" for yes and "2" for no from checkbox in Part I, Line 12g, Row D, Column (iv).
(21)
Amount of Support D
12G(V)D $
Enter the amount on Part I, Line 12g, Row D, Column (v).
(22)
EIN E
12G(II)E
Enter the EIN in Part I, Line 12g, Row E, Column (ii).
(23)
Type of Org E
12G(III)E
Enter the type of organization in Part I, Line 12g, Row E, Column (iii).
(24)
Listed in Governing Doc E
12G(IV)E
Enter "1" for yes and "2" for no from checkbox in Part I, Line 12g, Row E, Column (iv).
(25)
Amount of Support E
12G(V)E $
Enter the amount on Part I, Line 12g, Row E, Column (v).
(26)
Filling Field
N/A
Blank field generated on output.
(27)
Total Number of Organizations
12G(I)TOT
Enter the number from Schedule A, Part I, Line 12h, Column (i), Total Line.
(28)
Total Amount of Support
GVTOT $
Enter the amount on Part I, Line 12g, Total, Column (v).
(29)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(30)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(31)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(32)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(33)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(34)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(35)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(36)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(37)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(38)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(39)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(40)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(41)
First 5 Years Checkbox
13CKBX
Enter a "1" if the box on Schedule A, Part II, Line 13 is checked.
(42)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 16a is checked.
(43)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 16b is checked.
(44)
10% Facts & Circumstances Current
17ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 17a is checked.
(45)
10% Facts & Circumstances Prior
17BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 17b is checked.
(46)
Private Foundation Checkbox
18CKBX
Enter a "1" if the box on Schedule A, Part II, Line 18 is checked.
Form 990 - Section 12, Schedule A (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter a "1" if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter a "1" if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter a "1" if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter a "1" if the box on Schedule A, Part III, Line 20 is checked.
(23)
Part IV Section A Data Present Indicator
PTIVA
Enter a "1" if data is present in Part IV, Section A.
(24)
Part IV Section B Data Present Indicator
PTIVB
Enter a "1" if data is present in Part IV, Section B.
(25)
Part IV Section C Data Present Indicator
PTIVC
Enter a "1" if data is present in Part IV, Section C.
(26)
Part IV Section D Data Present Indicator
PTIVD
Enter a "1" if data is present in Part IV, Section D.
(27)
Part IV Section E Data Present Indicator
PTIVE
Enter a "1" if data is present in Part IV, Section E.
(28)
Filling Field
N/A
Generates a blank field on output.
(29)
Excess Distributions C
PTVE3C $
Enter the amount from Part V, Section E, Line 3c.
(30)
Excess Distributions D
PTVE3D $
Enter the amount from Part V, Section E, Line 3d.
(31)
Excess Distributions E
PTVE3E $
Enter the amount from Part V, Section E, Line 3e.
(32)
Excess Distributions Breakdown B
PTVE8B
Enter the amount from Part V, Section E, Line 3b.
(33)
Excess Distributions Breakdown C
PTVE8C
Enter the amount from Part V, Section E, Line 3c.
(34)
Excess Distributions Breakdown D
PTVE8D
Enter the amount from Part V, Section E, Line 3d.
(35)
Excess Distributions Breakdown E
PTVE8E
Enter the amount from Part V, Section E, Line 3e.
Form 990 - Section 13, Schedules C & D (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHIAL2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Total Number at EOY
SCHDL1(A)
Enter the number shown on Schedule D, Part I, Line 1, Column (a).
(4)
Contributions To
L2(A) $
Enter the amount from Schedule D, Part I, Line 2, Column (a).
(5)
Grants From
L3(A) $
Enter the amount from Schedule D, Part I, Line 3, Column (a).
(6)
Aggregate Value
L4(A) $
Enter the amount from Schedule D, Part I, Line 4, Column (a).
(7)
Inform All Donors Checkbox
L5
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 5.
(8)
Inform All Grantees Checkbox
L6
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 6.
Form 990 - Section 31, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Financial Assistance
L1A
Enter the following from the checkbox Schedule H, Part I, Line 1a:
1 = yes
2 = no.
(3)
Written Policy
L1B
Enter the following from the checkbox Schedule H, Part I, Line 1b:
1 = yes
2 = no.
(4)
Best Describes
L2
Enter the following:
1 = Applied Uniformly to all.
2 = Applied Uniformly to most.
3 = Generally tailored.
(5)
FPG Used
L3A
Enter the following from the checkbox Schedule H, Part I, Line 3a:
1 = yes
2 = no.
(6)
FPG%
L3A%
Enter the following from Schedule H, Part I, Line 3a percent:
1 = 100%
2 = 150%
3 = 200%
4 = Other.
(7)
FPG Discounted Care
L3B
Enter the following from the checkbox Schedule H, Part I, Line 3b:
1 = yes
2 = no.
(8)
FPG Discounted Care %
L3B%
Enter the percent that is next to the marked box from Schedule H, Part I, Line 3b percent:
1 = 200%
2 = 250%
3 = 300%
4 = 350%
5 = 400%
6 = Other
If more than one box is checked, enter the number for the largest percent.
(9)
Applied to Largest Number of Patients
L4
Enter the following from the checkbox Schedule H, Part I, Line 4:
1 = yes
2 = no.
(10)
Budget Amounts for Free or Discounted
L5A
Enter the following from the checkbox Schedule H, Part I, Line 5a:
1 = yes
2 = no.
(11)
Exceed Budget Amount
L5B
Enter the following from the checkbox Schedule H, Part I, Line 5b:
1 = yes
2 = no.
(12)
Unable to Provide Free or Discounted Care
L5C
Enter the following from the checkbox Schedule H, Part I, Line 5c:
1 = yes
2 = no.
(13)
Prepare A Community Benefit Report
L6A
Enter the following from the checkbox Schedule H, Part I, Line 6a:
1 = yes
2 = no.
(14)
Available to Public
L6B
Enter the following from the checkbox Schedule H, Part I, Line 6b:
1 = yes
2 = no.
(15)
Financial Assistance C
L7AC $
Enter the amount from Schedule H, Part I, Line 7a, Column (c).
(16)
Financial D
L7AD $
Enter the amount from Schedule H, Part I, Line 7a, Column (d).
(17)
Financial Assistance at Cost Net Community
SCHH 7A(E) $
Enter the amount from Schedule H, Part I, Line 7a, Column (e).
(18)
Financial Assistance at Cost Percent
7A(F)
Enter the percent from Schedule H, Part I, Line 7a, Column (f).
(19)
Medicaid C
L7BC $
Enter the amount from Schedule H, Part I, Line 7b, Column (c).
(20)
Medicaid D
L7BD $
Enter the amount from Schedule H, Part I, Line 7b, Column (d).
(21)
Unreimbursed Medicaid Net Community
7B(E) $
Enter the amount from Schedule H, Part I, Line 7b, Column (e).
(22)
Unreimbursed Medicaid Percent
7B(F)
Enter the percent from Schedule H, Part I, Line 7b, Column (f).
(23)
Cost of Other Means Tested C
L7CC $
Enter the amount from Schedule H, Part I, Line 7c, Column (c).
(24)
Cost of Other Means Tested D
L7DC $
Enter the amount from Schedule H, Part I, Line 7c, Column (d).
(25)
Unreimbursed Costs - Other Net Community
7C(E) $
Enter the amount from Schedule H, Part I, Line 7c, Column (e).
(26)
Unreimbursed Costs - Other Percent
7C(F)
Enter the percent from Schedule H, Part I, Line 7c, Column (f).
(27)
Financial Assistance Total C
7DC $
Enter the amount from Schedule H, Part I, Line 7d, Column (c).
(28)
Financial Assistance Total D
7DD $
Enter the amount from Schedule H, Part I, Line 7d, Column (d).
(29)
Total Financial Assistance Net Community
7D(E) $
Enter the amount from Schedule H, Part I, Line 7d, Column (e).
(30)
Total Financial Assistance Percent
7D(F)
Enter the percent from Schedule H, Part I, Line 7d, Column (f).
Form 990 - Section 32, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Community Health Improvement C
7EC $
Enter the amount from Schedule H, Part I, Line 7e, Column (c).
(3)
Community Health Improvement D
7ED $
Enter the amount from Schedule H, Part I, Line 7e, Column (d).
(4)
Community Health Improvement E
7EE $
Enter the amount from Schedule H, Part I, Line 7e, Column (e).
(5)
Community Health Improvement Percent
7EF%
Enter the percent from Schedule H, Part I, Line 7e, Column (f).
(6)
Health Professions C
7FC $
Enter the amount from Schedule H, Part I, Line 7f, Column (c).
(7)
Health Professions D
7ED $
Enter the amount from Schedule H, Part I, Line 7f, Column (d).
(8)
Health Professions E
7FE $
Enter the amount from Schedule H, Part I, Line 7f, Column (e).
(9)
Health Professions Percent
7FF%
Enter the percent from Schedule H, Part I, Line 7f, Column (f).
(10)
Subsidized Health Services C
7GC $
Enter the amount from Schedule H, Part I, Line 7g, Column (c).
(11)
Subsidized Health Services D
7GD $
Enter the amount from Schedule H, Part I, Line 7g, Column (d).
(12)
Subsidized Health Services E
7GE $
Enter the amount from Schedule H, Part I, Line 7g, Column (e).
(13)
Subsidized Health Services Percent
7GF%
Enter the percent from Schedule H, Part I, Line 7g, Column (f).
(14)
Research C
7HC $
Enter the amount from Schedule H, Part I, Line 7h, Column (c).
(15)
Research D
7HD $
Enter the amount from Schedule H, Part I, Line 7h, Column (d).
(16)
Research E
7HE $
Enter the amount from Schedule H, Part I, Line 7h, Column (e).
(17)
Research F Percent
7HF%
Enter the percent from Schedule H, Part I, Line 7h, Column (f).
(18)
Cash & Contributions C
7IC $
Enter the amount from Schedule H, Part I, Line 7i, Column (c).
(19)
Cash & Contributions D
7ID $
Enter the amount from Schedule H, Part I, Line 7i, Column (d).
(20)
Cash & Contributions E
7IE $
Enter the amount from Schedule H, Part I, Line 7i, Column (e).
(21)
Cash & Contributions %
7IF%
Enter the percent from Schedule H, Part I, Line 7i, Column (f).
(22)
Total Other Benefits C
7JC $
Enter the amount from Schedule H, Part I, Line 7j, Column (c).
(23)
Total Other Benefits D
7JD $
Enter the amount from Schedule H, Part I, Line 7j, Column (d).
(24)
Total Other Benefits E
7JE $
Enter the amount from Schedule H, Part I, Line 7j, Column (e).
(25)
Total Other Benefits Percent
7JF%
Enter the percent from Schedule H, Part I, Line 7j, Column (f).
(26)
Total C
7KC $
Enter the amount from Schedule H, Part I, Line 7k, Column (c).
(27)
Total D
7KD $
Enter the amount from Schedule H, Part I, Line 7k, Column (d).
(28)
Total E
7KE $
Enter the amount from Schedule H, Part I, Line 7k, Column (e).
(29)
Total Percent
7KF%
Enter the percent from Schedule H, Part I, Line 7k, Column (f).
Form 990 - Section 33, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Net Community
PIII0E $
Enter the amount from Schedule H, Part II, Line 10, Column (e).
(3)
Total Percent of Expense
10F%
Enter the percent from Schedule H, Part II, Line 10 Column (f).
(4)
Report Bad Debt Expense
PT3L1
Enter a yes or no from the yes/no box on Sch H, Part III, Line 1.
(5)
Bad Debt Expense Amount
L2 $
Enter the amount from Schedule H, Part III, Line 2.
(6)
Estimated Bad Debt Expense Amount
L3 $
Enter the amount from Schedule H, Part III, Line 3.
(7)
Revenue from Medicare
L5 $
Enter the amount from Schedule H, Part III, Line 5.
(8)
Medicare Allowable Costs
L6 $
Enter the amount from Schedule H, Part III, Line 6.
(9)
Medicare Surplus or Shortfall
L7 $
Enter the amount from Schedule H, Part III, Line 7.
(10)
Costing Methodology or Source Code
L8CD
Enter the edited code from the right of the boxes from Schedule H, Part III, Line 8.
(11)
Written Debt Collection Policy
L9A
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9a.
(12)
Collection Policy Contain Provision
L9B
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9b.
(13)
Part IV Code
PIVCD
Enter the edited digit from Schedule H, Part IV, right margin.
(14)
Part V How Many Hospital Facilities Did Organization Operate
SECATOP
Enter the number shown in the Hospital Facilities area in the top left portion of Schedule H, Part V, Section A.
(15)
Part V Section C Indicator Code
SECCRM
Enter the indicator code from Schedule H, Part V, Section C, right margin.
(16)
Part V How Many Non-Hospital Facilities Did Organization Operate
SECCTOP
Enter the number from the non-hospital health care benefits line.
(17)
Part V Section D Indicator Code
SECTDRM
Enter the edited code from Schedule H, Part V, Section D, right margin.
Form 990 - Section 34, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 35, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 36, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 37, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 38, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(25)
Other Similar Actions
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(26)
None of These Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
Form 990 - Section 39, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 40, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 41, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 42, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 43, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 44, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 45, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 46, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 47, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 48, Schedule H (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 49, Schedules L and R (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Excess Benefit Transactions
PT1RTMAR
Enter the edited digit from the right margin of Schedule L, Part 1.
(3)
Approved by Board or Committee
PT2RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
(4)
Interest, Annuities, Royalties, Yes/No Box
SCHRPT51A
Enter a yes or a no from the yes/no box from Schedule R, Part V, Line 1a.
Form 990 - Section 01 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section 01 always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generated the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4 for procedures.
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4 for procedures.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
For a CP 425–431 & 259A-259H, underlined to the right of the Employer ID Number.
See standard rules in IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter Y or N as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under title of form.
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
For a CP 425–431 & 259A-259H, edited in the area around the Tax Period.
(10)
In Care of Name Line
C/O NAME
Enter the in-care-of name, if shown.
Note:¶
Downstream processing generates the (%) sign.
(11)
Foreign Address
FGN ADD
Enter the foreign street address, if shown. See IRM 3.24.38 for additional instructions.
(12)
Street Address
ADDR
Enter the street address from the address line.
See IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information, even if prompted to do so. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(13)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country code.
(14)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.).
(15)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
(16)
Group Code H(b)
BOXHB
Enter a 1 or 2 from the yes/no box from the entity area of the return, Line H(b). For a CP425–431 & 259A-259H, press
(17)
Tax Exempt Status
BOXI
Enter the edited two digit code from the blank space of Box I.
(18)
Type of Organization
BOXK RT
Enter the edited code from the blank space of Box K. For a CP 425–431 & 259A-259H always enter a 9.
(19)
Computer Condition Codes
CCC
Enter the edited characters as shown on dotted portion of Lines 2–7b. For a 420–431 & 259A-259H, enter the edited characters as shown in the center of the return. If a Condition Code is illegible, enter a # in its place.
(20)
Return Processing Code
RPC
Enter the edited codes on Page 1, in the right margin next to line 1.
(21)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM 3.24.38 for special instructions.
f a "G" Condition Code is present and the return is non-remittance, end the document after this element.
If a CP 425–431 & 259A-259H, end the document after this element.
(22)
Preparation Code
PREP
Enter the edited code from the right of the preparer PTIN Line.
(23)
Preparer PTIN
PTIN
Enter the Preparer's PTIN.
(24)
Preparer's EIN
PEIN
Enter the preparer's EIN.
(25)
Preparer Telephone #
TEL#
Enter the preparer phone number.
If the Type of Organization is a "9" , and the "9" is underlined, don't end the document. Continue transcribing the return.
If Type of Organization is a "9" , and the "9" is NOT underlined, press
(26)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and the return is a remittance, Press
If the Type of Organization is "9" from Section 01 E–10 and the " 9" is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is "9" , and the "9" is NOT underlined, press
Form 990 - Section 02 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(3)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(4)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(5)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800, in MMDDYY format.
For special instructions, see IRM 3.24.38.
(6)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990 - Section 03 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return, ONLY if underlined in green.
(3)
IRI Codes
PG2TOP
Enter the edited digits from the top of page 2.
(4)
Undertake New Activities Y/N
L2
Enter a yes or no from the yes/no box from Part III, Line 2.
(5)
Make Significant Changes Y/N
L3
Enter a yes or no from the yes/no box from Part III, Line 3.
(6)
Exempt Purpose Code 1
L4A
Press Enter only. Don't transcribe a code.
(7)
Exempt Purpose Code 2
L4B
Press Enter only. Don't transcribe a code.
(8)
Exempt Purpose Code 3
L4C
Press Enter only. Don't transcribe a code.
(9)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
Note:¶
If a "D1" is edited and underlined, pick up as an alpha "D" and numeric "1" . Don't confuse with an alpha "D" and alpha "I" .
(10)
501(c)(3) or 4947(a)(1) Y/N
L1
Enter a yes or no from the yes/no box from Part IV, Line 1.
(11)
Required to Complete Sch B Y/N
L2
Enter a yes or no from the yes/no box from Part IV, Line 2.
(12)
Engage in Direct or Indirect Political Y/N
L3
Enter a yes or no from the yes/no box from Part IV, Line 3.
(13)
Engage in Lobbying Activities Y/N
L4
Enter a yes or no from the yes/no box from Part IV, Line 4.
(14)
Subject to Sec 6033(c) Notice
L5
Enter a yes or no from the yes/no box from Part IV, Line 5.
(15)
Maintain Donor Advised Y/N
L6
Enter a yes or no from the yes/no box from Part IV, Line 6.
(16)
Receive or Hold Conservation Y/N
L7
Enter a yes or no from the yes/no box from Part IV, Line 7.
(17)
Maintain Collections of Works of Art Y/N
L8
Enter a yes or no from the yes/no box from Part IV, Line 8.
(18)
Provide Credit Counseling Y/N
L9
Enter a yes or no from the yes/no box from Part IV, Line 9.
(19)
Hold Assets in Term/Permanent Y/N
L10
Enter a yes or no from the yes/no box from Part IV, Line 10.
(20)
Land, Buildings, Equipment
11A
Enter a yes or no from the yes/no box from Part IV, Line 11a.
(21)
Investments Other Securities
11B
Enter a yes or no from the yes/no box from Part IV, Line 11b.
(22)
Investments Program Related
11C
Enter a yes or no from the yes/no box from Part IV, Line 11c.
(23)
Other Assets
11D
Enter a yes or no from the yes/no box from Part IV, Line 11d.
(24)
Other Liabilities
11E
Enter a yes or no from the yes/no box from Part IV, Line 11e.
(25)
Separate or Consolidated Financial Statements
11F
Enter a yes or no from the yes/no box from Part IV, Line 11f.
(26)
Separate Independent Audited Financial
12A
Enter a yes or no from the yes/no box from Part IV, Line 12a.
(27)
Consolidated Independent Financial
12B
Enter a yes or no from the yes/no box from Part IV, Line 12b.
(28)
School Described in 170(b)(1)(A)(ii)
L13
Enter a yes or no from the yes/no box from Part IV, Line 13.
(29)
Maintain an Office, etc Outside U.S.
14A
Enter a yes or no from the yes/no box from Part IV, Line 14a.
(30)
Have Aggregate Revenues/Expenses
14B
Enter a yes or no from the yes/no box from Part IV, Line 14b.
(31)
Report > $5000 on Part IX Organizations
L15
Enter a yes or no from the yes/no box from Part IV, Line 15.
(32)
Report > $5000 on Part IX Individuals
L16
Enter a yes or no from the yes/no box from Part IV, Line 16.
(33)
Report > $15,000 on Part IX, Line 11e
L17
Enter a yes or no from the yes/no box from Part IV, Line 17.
(34)
Report > $15,000 on Part VIII, Line 1c/8a
L18
Enter a yes or no from the yes/no box from Part IV, Line 18.
(35)
Report > $15,000 on Part VIII, Line 9a
L19
Enter a yes or no from the yes/no box from Part IV, Line 19.
(36)
Operate Hospitals
20A
Enter a yes or no from the yes/no box from Part IV, Line 20a.
(37)
Attach Audited Financial Statements
20B
Enter a yes or no from the yes/no box from Part IV, Line 20b.
Form 990 - Section 04 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Report > $5000 on Part IX, Line 1
L21
Enter a yes or no from the yes/no box from Part IV, Line 21.
(3)
Report > $5000 on Part IX, Line 2
L22
Enter a yes or no from the yes/no box from Part IV, Line 22.
(4)
Answer Yes to Questions 3, 4, 5
L23
Enter a yes or no from the yes/no box from Part IV, Line 23.
(5)
Any Tax-Exempt Bond with Outstanding Principal
24A
Enter a yes or no from the yes/no box from Part IV, Line 24a.
(6)
Invest Any Proceeds
24B
Enter a yes or no from the yes/no box from Part IV, Line 24b.
(7)
Maintain an Escrow Account
24C
Enter a yes or no from the yes/box from Part IV, Line 24c.
(8)
Act as On Behalf Of Issuer
24D
Enter a yes or no from the yes/no box from Part IV, Line 24d.
(9)
501(c)(3) / 501(c)(4) Organizations
25A
Enter a yes or no from the yes/no box from Part IV, Line 25a.
(10)
Become Aware it Engaged in Excess
25B
Enter a yes or no from the yes/no box from Part IV, Line 25b.
(11)
Loan to/by Current/Former Officer
L26
Enter a yes or no from the yes/no box from Part IV, Line 26.
(12)
Provide Grant or Other Assistance
L27
Enter a yes or no from the yes/no box from Part IV, Line 27.
(13)
Business Transaction with Current or Former Officer
28A
Enter a yes or no from the yes/no box from Part IV, Line 28a.
(14)
Business Transaction with Family Member
28B
Enter a yes or no from the yes/no box from Part IV, Line 28b.
(15)
Business Transaction with Entity of Current/ Former Officer
28C
Enter a yes or no from the yes/no box from Part IV, Line 28c.
(16)
Receive or Accrue > $25,000 in Non-Cash
L29
Enter a yes or no from the yes/no box from Part IV, Line 29.
(17)
Receive or Accrue Contributions of Art
L30
Enter a yes or no from the yes/no box from Part IV, Line 30.
(18)
Liquidate, Terminate, Dissolve
L31
Enter a yes or no from the yes/no box from Part IV, Line 31.
(19)
Sell, Exchange, Dispose
L32
Enter a yes or no from the yes/no box from Part IV, Line 32.
(20)
Own 100% of an Entity
L33
Enter a yes or no from the yes/no box from Part IV, Line 33.
(21)
Related to Tax-Exempt / Taxable Entity
L34
Enter a yes or no from the yes/no box from Part IV, Line 34.
(22)
Controlled Entity Within 512(b)(13)
L35A
Enter a yes or no from the yes/no box from Part IV, Line 35a.
(23)
Receive Payment or Engage Transaction Within
35B
Enter a yes or no from the yes/no box from Part IV, Line 35b.
(24)
Make Any Transfers
L36
Enter a yes or no from the yes/no box from Part IV, Line 36.
(25)
Conduct More than 5%
L37
Enter a yes or no from the yes/no box from Part IV, Line 37.
(26)
Complete Schedule O
L38
Enter a yes or no from the yes/no box from Part IV, Line 38.
Form 990 - Section 05 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part V Number of Forms/1096
PTVL1A
Enter the number shown on Part V, Line 1a.
(3)
Number of Forms W-2G
L1B
Enter the number shown on Part V, Line 1b.
(4)
Comply with Backup Withholding Rules
L1C
Enter a yes or no from the yes/no box from Part V, Line 1c.
(5)
Number of Employees / W-3
L2A
Enter the number shown on Part V, Line 2a.
(6)
File All Required Federal Employment Returns
L2B
Enter a yes or no from the yes/no box from Part V, Line 2b.
(7)
Unrelated Business Income > $1000
L3A
Enter a yes or no from the yes/box from Part V, Line 3a.
(8)
If Yes, Has Filed a 990-T
L3B
Enter a yes or no from the yes/no box from Part V, Line 3b.
(9)
Interest in or a Signature
L4A
Enter a yes or no from the yes/no box from Part V, Line 4a.
(10)
Party to a Prohibited Tax Shelter
L5A
Enter a yes or no from the yes/no box from Part V, Line 5a.
(11)
Taxable Party Notify Organization
L5B
Enter a yes or no from the yes/no box from Part V, Line 5b.
(12)
If Yes, Did Organization File 8886-T
L5C
Enter a yes or no from the yes/no box from Part V, Line 5c.
(13)
Annual Gross Receipts Normally >$100,000
L6A
Enter a yes or no from the yes/no box from Part V, Line 6a.
(14)
If Yes, Did Organization Include
L6B
Enter a yes or no from the yes/no box from Part V, Line 6b.
(15)
$75 Partly Contribution/Goods/Services
L7A
Enter a yes or no from the yes/no box from Part V, Line 7a.
(16)
If Yes, Did Organization Notify Donor
L7B
Enter a yes or no from the yes/no box from Part V, Line 7b.
(17)
Sell, Exchange, Otherwise Dispose
L7C
Enter a yes or no from the yes/no box from Part V, Line 7c.
(18)
Number of Forms 8282
L7D
Enter the number shown on Part V, Line 7d.
(19)
Receive Any Funds
L7E
Enter a yes or no from the yes/no box from Part V, Line 7e.
(20)
Pay Premiums
L7F
Enter a yes or no from the yes/no box from Part V, Line 7f.
(21)
Contributions of Qualified Intellectual Property
L7G
Enter a yes or no from the yes/no box from Part V, Line 7g.
(22)
Contributions of Cars, Boats, Airplanes
L7H
Enter a yes or no from the yes/no box from Part V, Line 7h.
(23)
Sponsoring Orgs, 509(a)(3) Excess Business Holdings
L8
Enter a yes or no from the yes/no box from Part V, Line 8.
(24)
Make Taxable Distributions Under 4966
L9A
Enter a yes or no from the yes/no box from Part V, Line 9a.
(25)
Make Distribution to Donor
L9B
Enter a yes or no from the yes/no box from Part V, Line 9b.
(26)
Initiation Fees/Capital Contributions
10A $
Enter the amount from Part V, Line 10a.
(27)
Gross Receipts for Public Use of Facilities
10B $
Enter the amount from Part V, Line 10b.
(28)
Gross Income/Members/Shareholders
11A $
Enter the amount from Part V, Line 11a.
(29)
Gross Income from Other Sources
11B $
Enter the amount from Part V, Line 11b.
(30)
4947(a)(1) Filing 990 in Lieu of 1041
12A
Enter a yes or no from the yes/no box from Part V, Line 12a.
(31)
Amount of Tax Exempt Interest
12B $
Enter the amount from Part V, Line 12b.
(32)
Licensed to Issue Qualified Health Plans
13A
Enter a yes or no from the yes/no box from Part V, Line 13a.
(33)
Aggregate Amount of Reserves to Maintain
13B $
Enter the amount from Part V, Line 13b.
(34)
Aggregate Amount of Reserves on Hand
13C $
Enter the amount from Part V, Line 13c.
(35)
Receive Payments for Indoor Tanning
14A
Enter a yes or no from the yes/no box from Part V, Line 14a.
(36)
Filed Form 720 to Report Payments
14B
Enter a yes or no from the yes/no box from Part V, Line 14b.
Form 990 - Section 06 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Voting Members of Governing Body
PG6L1A
Enter the number shown on Part VI, Section A, Line 1a.
(3)
Independent Voting Members
L1B
Enter the number shown on Part VI, Section A, Line 1b.
(4)
Officer, Director, Trustee Family/Relationship
L2
Enter a yes or no from the yes/no box from Part VI, Section A, Line 2.
(5)
Delegate Control Over Management
L3
Enter a yes or no from the yes/no box from Part VI, Section A, Line 3.
(6)
Make Significant Changes
L4
Enter a yes or no from the yes/no box from Part VI, Section A, Line 4.
(7)
Become Aware of Material Diversion
L5
Enter a yes or no from the yes/box from Part VI, Section A, Line 5.
(8)
Members of Stockholders
L6
Enter a yes or no from the yes/no box from Part VI, Section A, Line 6.
(9)
Members, Stockholders, Other Persons
7A
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7a.
(10)
Members Subject to Approval
7B
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7b.
(11)
Determining Compensation for CEO, Exec Director
15A
Enter a yes or no from the yes/no box from Part VI, Section B, Line 15a.
(12)
Total Reportable Compensation from Organization
PG8L1D(D) $
Enter the amount from Part VII, Section A, Line 1d, Column D.
(13)
Total Reportable Compensation from Related Organization
1D(E) $
Enter the amount from Part VII, Section A, Line 1d, Column E.
(14)
Total Compensation from Organization & Related Organizations
1D(F) $
Enter the amount from Part VII, Section A, Line 1d, Column F.
(15)
Total Individuals who Received > $100,000
SECTAL2
Enter the number shown on Part VII, Section A, Line 2.
(16)
Total Independent Contractors Received > $100,000
SECTBL2
Enter the number shown on Part VII, Section B, Line 2.
Form 990 - Section 07 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Contributions/ Gifts/Grants
PG9L1H $
Enter the amount from Part VIII, Line 1h, Column (A).
(3)
Program Service Business Code 2A
2ACODE
Enter the number shown on Part VIII, Line 2a.
(4)
2a Program Service Revenue Col. A
2A(A) $
Enter the amount from Part VIII, Line 2a, Column (A).
(5)
Program Service Business Code 2B
2BCODE
Enter the number shown on Part VIII, Line 2b.
(6)
2b Program Service Revenue Col. A
2B(A) $
Enter the amount from Part VIII, Line 2b, Column (A).
(7)
Program Service Business Code 2C
2CCODE
Enter the number shown on Part VIII, Line 2c.
(8)
2c Program Service Revenue Col. A
2C(A) $
Enter amount shown on Part VIII, Line 2c, Column (A).
(9)
Program Service Business Code 2D
2DCODE
Enter the number shown on Part VIII, Line 2d.
(10)
2d Program Service Revenue Col. A
2D(A) $
Enter amount shown on Part VIII, Line 2d, Column (A).
(11)
Program Service Business Code 2E
2ECODE
Enter the number shown on Part VIII, Line 2e.
(12)
2e Program Service Revenue Col. A
2E(A) $
Enter the amount from Part VIII, Line 2e, Column (A).
(13)
2f Program Service Revenue Col. A
2F(A) $
Enter the amount from Part VIII, Line 2f, Column (A).
(14)
2g Program Service Revenue Total Col. A
2GTOT $
Enter the amount from Part VIII, Line 2g, Column (A).
(15)
Investment Income Col. A
3(A) $
Enter the amount from Part VIII, Line 3, Column (A).
(16)
Tax-Exempt Bond Proceeds Col. A
4(A) $
Enter the amount from Part VIII, Line 4, Column (A).
(17)
Royalties Col. A
5(A) $
Enter the amount from Part VIII, Line 5, Column (A).
(18)
Gross Rents Real
6(A)I $
Enter the amount from Part VIII, Line 6a, Column (i).
(19)
Gross Rents Personal
6(A)II $
Enter the amount from Part VIII, Line 6a, Column (ii).
(20)
Rental Expenses Real
6(B)(I) $
Enter the amount from Part VIII, Line 6b, Column (i).
(21)
Rental Expenses Personal
6(B)(II) $
Enter the amount from Part VIII, Line 6b, Column (ii).
(22)
Rental Income/Loss Real
6C(I) $
Enter the amount from Part VIII, Line 6c, Column (i).
(23)
Rental Income/Loss Personal
6C(II) $
Enter the amount from Part VIII, Line 6c, Column (ii).
(24)
Net Rental Income/Loss Col. A
6D(A) $
Enter the amount from Part VIII, Line 6d, Column (A).
Form 990 - Section 08 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross Amount from Sales of Assets - Securities
PG9L7A(I) $
Enter the amount from Part VIII, Line 7a, Column (i).
(3)
Gross Amount from Sales of Assets - Other
7A(II) $
Enter the amount from Part VIII, Line 7a, Column (ii).
(4)
Cost or Other Basis/Sales - Securities
7B(I) $
Enter the amount from Part VIII, Line 7b, Column (i).
(5)
Cost or Other Basis/Sales - Other
7B(II) $
Enter the amount from Part VIII, Line 7b, Column (ii).
(6)
Gain/Loss - Securities
7C(I) $
Enter the amount from Part VIII, Line 7c, Column (i).
(7)
Gain/Loss - Other
7C(II) $
Enter the amount from Part VIII, Line 7c, Column (ii).
(8)
Net Gain/Loss Col. A
7D(A) $
Enter the amount from Part VIII, Line 7d, Column (A).
(9)
Gross Income from Fundraising
8A $
Enter the amount from Part VIII, Line 8a.
(10)
Less Direct Expenses 8b
8B $
Enter the amount from Part VIII, Line 8b.
(11)
Net Income/Loss from Fundraising Col. A
8C(A) $
Enter the amount from Part VIII, Line 8c, Column (A).
(12)
Gross Income from Gaming
9A $
Enter the amount from Part VIII, Line 9a.
(13)
Less Direct Expenses 9b
9B $
Enter the amount from Part VIII, Line 9b.
(14)
Net Income/Loss from Gaming
9C(A) $
Enter the amount from Part VIII, Line 9c, Column (A).
(15)
Gross Sales of Inventory
10A $
Enter the amount from Part VIII, Line 10a.
(16)
Less Cost of Goods Sold
10B $
Enter the amount from Part VIII, Line 10b.
(17)
Net Income/Loss from Sales Col. A
10C(A) $
Enter the amount from Part VIII, Line 10c, Column (A).
(18)
Misc. Revenue Business Code 11a
11ACODE
Enter the number shown on Part VIII, Line 11a.
(19)
Misc. Revenue Total (A) Col. A
11A(A) $
Enter the amount from Part VIII, Line 11a, Column (A).
(20)
Misc. Revenue Business Code 11b
11BCODE
Enter the number shown on Part VIII, Line 11b.
(21)
Misc. Revenue Total 11B(A) Col. A
11B(A) $
Enter the amount from Part VIII, Line 11b, Column (A).
(22)
Misc. Revenue Business Code 11c
11CCODE
Enter the number shown on Part VIII, Line 11c.
(23)
Misc. Revenue Total 11C(A) Col. A
11C(A) $
Enter the amount from Part VIII, Line 11c, Column (A).
(24)
Misc. Revenue Total 11D(A) Col. A
11D(A) $
Enter the amount from Part VIII, Line 11d, Column (A).
(25)
Misc. Revenue Total 11E Col. A
11ETOT $
Enter the amount from Part VIII, Line 11e, Column (A).
(26)
Total Revenue 12(A) Col. A
12(A) $
Enter the amount from Part VIII, Line 12, Column (A).
Form 990 - Section 09 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross to Government / Organizations in U.S.
PG10L1(A) $
Enter the amount from Part IX, Line 1, Column (A).
(3)
Grants / Other Assistance in U.S.
L2(A) $
Enter the amount from Part IX, Line 2, Column (A).
(4)
Grants / Other Assistance Outside U.S.
L3(A) $
Enter the amount from Part IX, Line 3, Column (A).
(5)
Benefits Paid to / for Members
L4(A) $
Enter the amount from Part IX, Line 4, Column (A).
(6)
Compensation of Current Officers / Directors
L5(A) $
Enter the amount from Part IX, Line 5, Column (A).
(7)
Compensation to Disqualified Persons
L6(A) $
Enter the amount from Part IX, Line 6, Column (A).
(8)
Other Salaries / Wages
L7(A) $
Enter the amount from Part IX, Line 7, Column (A).
(9)
Pension Plan Contributions
L8(A) $
Enter the amount from Part IX, Line 8, Column (A).
(10)
Other Employee Benefits
L9(A) $
Enter the amount from Part IX, Line 9, Column (A).
(11)
Payroll Taxes
10(A) $
Enter the amount from Part IX, Line 10, Column (A).
(12)
Fees for Services / Management
11A(A) $
Enter the amount from Part IX, Line 11a, Column (A).
(13)
Fees for Services / Legal
11B(A) $
Enter the amount from Part IX, Line 11b, Column (A).
(14)
Fees for Services / Accounting
11C(A) $
Enter the amount from Part IX, Line 11c, Column (A).
(15)
Fees for Services / Lobbyists
11D(A) $
Enter the amount from Part IX, Line 11d, Column (A).
(16)
Fees for Services / Professional Fundraising
11E(A) $
Enter the amount from Part IX, Line 11e, Column(A).
(17)
Fees for Services / Investment Management
11F(A) $
Enter the amount from Part IX, Line 11f, Column (A).
(18)
Fees for Services / Other
11G(A) $
Enter the amount from shown on Part IX, Line 11g, Column (A).
(19)
Advertising / Promotion
12(A) $
Enter the amount from Part IX, Line 12, Column (A).
(20)
Office Expenses
13(A) $
Enter the amount from on Part IX, Line 13, Column (A).
(21)
Information Technology
14(A) $
Enter the amount from Part IX, Line 14, Column (A).
(22)
Royalties
15(A) $
Enter the amount from Part IX, Line 15, Column (A).
(23)
Occupancy
16(A) $
Enter the amount from Part IX, Line 16, Column (A).
(24)
Travel
17(A) $
Enter the amount from Part IX, Line 17, Column (A).
(25)
Payments of Travel / Entertainment
18(A) $
Enter the amount from Part IX, Line 18, Column (A).
(26)
Conferences, Conventions / Meetings
19(A) $
Enter the amount from Part IX, Line 19, Column (A).
(27)
Interest
20(A) $
Enter the amount from Part IX, Line 20, Column (A).
(28)
Payments to Affiliates
21(A) $
Enter the amount from Part IX, Line 21, Column (A).
(29)
Depreciation / Depletion
22(A) $
Enter the amount from Part IX, Line 22, Column (A).
(30)
Insurance
23(A) $
Enter the amount from Part IX, Line 23, Column (A).
(31)
Other Expenses a
24A(A) $
Enter the amount from Part IX, Line 24a, Column (A).
(32)
Other Expenses b
24B(A) $
Enter the amount from Part IX, Line 24b, Column (A).
(33)
Other Expenses c
24C(A) $
Enter the amount from Part IX, Line 24c, Column (A).
(34)
Other Expenses d
24D(A) $
Enter the amount from Part IX, Line 24d, Column (A).
(35)
Other Expenses e
24E(A) $
Enter the amount from Part IX, Line 24e, Column (A).
(36)
NA
24F(A) $
Enter only.
(37)
Total Functional Expenses
25(A) $
Enter the amount from Part IX, Line 25, Column (A).
Form 990 - Section 10 (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash EOY
PG11L1(B) $
Enter the amount from Part X, Line 1, Column (B).
(3)
Savings / Temporary Investments EOY
L2(B) $
Enter the amount from Part X, Line 2, Column (B).
(4)
Pledges / Grants Receivable EOY
L3(B) $
Enter the amount from Part X, Line 3, Column (B).
(5)
Accounts Receivable EOY
L4(B) $
Enter the amount from Part X, Line 4, Column (B).
(6)
Receivables from Current / Former EOY
L5(B) $
Enter the amount from Part X, Line 5, Column (B).
(7)
Receivables from Disqualified Persons EOY
L6(B) $
Enter the amount from Part X, Line 6, Column (B).
(8)
Notes / Loans Receivable EOY
L7(B) $
Enter the amount from Part X, Line 7, Column (B).
(9)
Inventories for Sale EOY
L8(B) $
Enter the amount from Part X, Line 8, Column (B).
(10)
Prepaid Expenses EOY
L9(B) $
Enter the amount from Part X, Line 9, Column (B).
(11)
Land / Buildings Less Accumulated EOY
10C(B) $
Enter the amount from Part X, Line 10c, Column (B).
(12)
Investments Publicly Traded Securities EOY
11(B) $
Enter the amount from Part X, Line 11, Column (B).
(13)
Investments Other Securities EOY
12(B) $
Enter the amount from Part X, Line 12, Column (B).
(14)
Investments Program Related EOY
13(B) $
Enter the amount from Part X, Line 13, Column (B).
(15)
Intangible Assets EOY
14(B) $
Enter the amount from Part X, Line 14, Column (B).
(16)
Other Assets EOY
15(B) $
Enter the amount from Part X, Line 15, Column(B).
(17)
Total Assets BOY
16(A) $
Enter the amount from Part X, Line 16, Column (A).
(18)
Total Assets EOY
16(B) $
Enter the amount from shown on Part X, Line 16, Column (B).
(19)
Accounts Payable EOY
17(B) $
Enter the amount from Part X, Line 17, Column (B).
(20)
Grants Payable EOY
18(B) $
Enter the amount from on Part X, Line 18, Column (B).
(21)
Deferred Revenue EOY
19(B) $
Enter the amount from Part X, Line 19, Column (B).
(22)
Tax-Exempt Bond Liabilities EOY
20(B) $
Enter the amount from Part X, Line 20, Column (B).
(23)
Escrow Liability EOY
21(B) $
Enter the amount from Part X, Line 21, Column (B).
(24)
Payable to Current / Former Officers EOY
22(B) $
Enter the amount from Part X, Line 22, Column (B).
(25)
Secured Mortgages / Notes EOY
23(B) $
Enter the amount from Part X, Line 23, Column (B).
(26)
Unsecured Notes / Loans EOY
24(B) $
Enter the amount from Part X, Line 24, Column (B).
(27)
Other Liabilities EOY
25(B) $
Enter the amount from Part X, Line 25, Column (B).
(28)
Total Liabilities BOY
26(A) $
Enter the amount from Part X, Line 26, Column (A).
(29)
Total Liabilities EOY
26(B) $
Enter the amount from Part X, Line 26, Column (B).
(30)
Unrestricted Net Assets EOY
27(B) $
Enter the amount from Part X, Line 27, Column (B).
(31)
Temporarily Restricted Net Assets EOY
28(B) $
Enter the amount from Part X, Line 28, Column (B).
(32)
Permanently Restricted Net Assets EOY
29(B) $
Enter the amount from Part X, Line 29, Column (B).
(33)
Capital Stock / Trust EOY
30(B) $
Enter the amount from Part X, Line 30, Column (B).
(34)
Paid-In / Capital Surplus EOY
31(B) $
Enter the amount from Part X, Line 31, Column (B).
(35)
Retained Earnings, Endowment EOY
32(B) $
Enter the amount from Part X, Line 32, Column (B).
(36)
Total Net Assets or Fund Balances BOY
33(A) $
Enter the amount from Part X, Line 33, Column (A).
(37)
Total Net Assets or Fund Balances EOY
33(B) $
Enter the amount from Part X, Line 33, Column (B).
(38)
Total Liabilities / Net Assets Fund Balances EOY
34(B) $
Enter the amount from Part X, Line 34, Column (B).
Form 990 - Section 11, Schedule A (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Type of Organization
L11
Enter one of the following from Line 12:
1 = Type I,
2 = Type II,
3 = Type III – Functionally integrated
4 = Type III – Non-functionally integrated Blank
If more than one box is checked, enter the corresponding number for the first box checked.
(4)
Type I, II or III Supporting Organization
11E
Enter a 1 if the box is checked on Schedule A, Part I, Line 12e.
(5)
Number of Supported Organizations
11F
Enter the number from Line 12f.
(6)
EIN A
12G(II)A
Enter the EIN in Part I, Line 12g, Row A, Column (ii).
(7)
Type of Org A
12G(III)A
Enter the type of organization in Part I, Line 12g, Row A, Column (iii).
(8)
Listed in Governing Doc A
12G(IV)A
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row A, Column (iv).
(9)
Amount of Support A
12G(V) A $
Enter the amount on Part I, Line 12g, Row A, Column (v).
(10)
EIN B
12G(II)B
Enter the EIN in Part I, Line 12g, Row B, Column (ii).
(11)
Type of Org B
12G(III)B
Enter the type of organization in Part I, Line 12g, Row B, Column (iii).
(12)
Listed in Governing Doc B
12G(IV)B
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row B, Column (iv).
(13)
Amount of Support B
12G(V)B $
Enter the amount Part I, Line 12g, Row B, Column (v).
(14)
EIN C
12G(II)C
Enter the EIN in Part I, Line 12g, Row C, Column (ii).
(15)
Type of Org C
12G(III)C
Enter the type of organization in Part I, Line 12g, Row C, Column (iii).
(16)
Listed in Governing Doc C
12G(IV)C
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row C, Column (iv).
(17)
Amount of Support C
12G(V)C $
Enter the amount on Part I, Line 12g, Row C, Column (v).
(18)
EIN D
12G(II)D
Enter the EIN in Part I, Line 12g, Row D, Column (ii).
(19)
Type of Org D
12G(III)D
Enter the type of organization in Part I, Line 12g, Row D, Column (iii).
(20)
Listed in Governing Doc D
12G(IV)D
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row D, Column (iv).
(21)
Amount of Support D
12G(V)D $
Enter the amount on Part I, Line 12g, Row D, Column (v).
(22)
EIN E
12G(II)E
Enter the EIN in Part I, Line 12g, Row E, Column (ii).
(23)
Type of Org E
12G(III)E
Enter the type of organization in Part I, Line 12g, Row E, Column (iii).
(24)
Listed in Governing Doc E
12G(IV)E
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row E, Column (iv).
(25)
Amount of Support E
12G(V)E $
Enter the amount on Part I, Line 12g, Row E, Column (v).
(26)
Filling Field
N/A
Blank field generated on output.
(27)
Total Number of Organizations
12G(I)TOT
Enter the number from Schedule A, Part I, Line 12g, Column (i), Total Line.
(28)
Total Amount of Support
GVTOT $
Enter the amount on Part I, Line 12g, Total, Column (v).
(29)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(30)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(31)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(32)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(33)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(34)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(35)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(36)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(37)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(38)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(39)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(40)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(41)
First 5 Years Checkbox
13CKBX
Enter a 1 if the box on Schedule A, Part II, Line 13 is checked.
(42)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter a 1 if the box on Schedule A, Part II, Line 16a is checked.
(43)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter a 1 if the box on Schedule A, Part II, Line 16b is checked.
(44)
10% Facts & Circumstances Current
17ACKBX
Enter a 1 if the box on Schedule A, Part II, Line 17a is checked.
(45)
10% Facts & Circumstances Prior
17BCKBX
Enter a 1 if the box on Schedule A, Part II, Line 17b is checked.
(46)
Private Foundation Checkbox
18CKBX
Enter a 1 if the box on Schedule A, Part II, Line 18 is checked.
Form 990 - Section 12, Schedule A (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter a 1 if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter a 1 if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter a 1 if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter a 1 if the box on Schedule A, Part III, Line 20 is checked.
(23)
Part IV Section A Data Present Indicator
PTIVA
Enter a 1 if data is present in Part IV, Section A.
(24)
Part IV Section B Data Present Indicator
PTIVB
Enter a 1 if data is present in Part IV, Section B.
(25)
Part IV Section C Data Present Indicator
PTIVC
Enter a 1 if data is present in Part IV, Section C.
(26)
Part IV Section D Data Present Indicator
PTIVD
Enter a 1 if data is present in Part IV, Section D.
(27)
Part IV Section E Data Present Indicator
PTIVE
Enter a 1 if data is present in Part IV, Section E.
(28)
Filling Field
N/A
Generates a blank field on output.
(29)
Excess Distributions C
PTVE3C $
Enter the amount from Part V, Section E, Line 3c.
(30)
Excess Distributions D
PTVE3D $
Enter the amount from Part V, Section E, Line 3d.
(31)
Excess Distributions E
PTVE3E $
Enter the amount from Part V, Section E, Line 3e.
(32)
Excess Distributions Breakdown B
PTVE8B $
Enter the amount from Part V, Section E, Line 8b.
(33)
Excess Distributions Breakdown C
PTVE8C $
Enter the amount from Part V, Section E, Line 8c.
(34)
Excess Distributions Breakdown D
PTVE8D $
Enter the amount from Part V, Section E, Line 8d.
(35)
Excess Distributions Breakdown E
PTVE8E $
Enter the amount from Part V, Section E, Line 8e.
Form 990 - Section 13, Schedules C & D (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHIAL2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Total Number at EOY
SCHDL1(A)
Enter the number shown on Schedule D, Part I, Line 1, Column (a).
(4)
Contributions To
L2(A) $
Enter the amount from Schedule D, Part I, Line 2, Column (a).
(5)
Grants From
L3(A) $
Enter the amount from Schedule D, Part I, Line 3, Column (a).
(6)
Aggregate Value
L4(A) $
Enter the amount from Schedule D, Part I, Line 4, Column (a).
(7)
Inform All Donors Checkbox
L5
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 5.
(8)
Inform All Grantees Checkbox
L6
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 6.
Form 990 - Section 31, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Financial Assistance
L1A
Enter the following from the checkbox Schedule H, Part I, Line 1a:
1 = yes
2 = no.
(3)
Written Policy
L1B
Enter the following from the checkbox Schedule H, Part I, Line 1b:
1 = yes
2 = no.
(4)
Best Describes
L2
Enter the following:
1 = Applied Uniformly to all.
2 = Applied Uniformly to most.
3 = Generally tailored.
(5)
FPG Used
L3A
Enter the following from the checkbox Schedule H, Part I, Line 3a:
1 = yes
2 = no.
(6)
FPG%
L3A%
Enter the percent that is next to the marked box from Schedule H, Part I, Line 3a percent:
1 = 100%
2 = 150%
3 = 200%
4 = Other.
(7)
FPG Discounted Care
L3B
Enter the following from the checkbox Schedule H, Part I, Line 3b:
1 = yes
2 = no.
(8)
FPG Discounted Care %
L3B%
Enter the percent that is next to the marked box from Schedule H, Part I, Line 3b percent:
1 = 200%
2 = 250%
3 = 300%
4 = 350%
5 = 400%
6 = Other
If more than one box is checked, enter the number for the largest percent.
(9)
Applied to Largest Number of Patients
L4
Enter the following from the checkbox Schedule H, Part I, Line 4:
1 = yes
2 = no.
(10)
Budget Amounts for Free or Discounted
L5A
Enter the following from the checkbox Schedule H, Part I, Line 5a:
1 = yes
2 = no.
(11)
Exceed Budget Amount
L5B
Enter the following from the checkbox Schedule H, Part I, Line 5b:
1 = yes
2 = no.
(12)
Unable to Provide Free or Discounted Care
L5C
Enter the following from the checkbox Schedule H, Part I, Line 5c:
1 = yes
2 = no.
(13)
Prepare A Community Benefit Report
L6A
Enter the following from the checkbox Schedule H, Part I, Line 6a:
1 = yes
2 = no.
(14)
Available to Public
L6B
Enter the following from the checkbox Schedule H, Part I, Line 6b:
1 = yes
2 = no.
(15)
Financial Assistance C
L7AC $
Enter the amount from Schedule H, Part I, Line 7a, Column (c).
(16)
Financial D
L7AD $
Enter the amount from Schedule H, Part I, Line 7a, Column (d).
(17)
Financial Assistance at Cost Net Community
SCHH 7A(E) $
Enter the amount from Schedule H, Part I, Line 7a, Column (e).
(18)
Financial Assistance at Cost Percent
7A(F)
Enter the percent from Schedule H, Part I, Line 7a, Column (f).
(19)
Medicaid C
L7BC $
Enter the amount from Schedule H, Part I, Line 7b, Column (c).
(20)
Medicaid D
L7BD $
Enter the amount from Schedule H, Part I, Line 7b, Column (d).
(21)
Unreimbursed Medicaid Net Community
7B(E) $
Enter the amount from Schedule H, Part I, Line 7b, Column (e).
(22)
Unreimbursed Medicaid Percent
7B(F)
Enter the percent from Schedule H, Part I, Line 7b, Column (f).
(23)
Cost of Other Means Tested C
L7CC $
Enter the amount from Schedule H, Part I, Line 7c, Column (c).
(24)
Cost of Other Means Tested D
L7DC $
Enter the amount from Schedule H, Part I, Line 7c, Column (d).
(25)
Unreimbursed Costs - Other Net Community
7C(E) $
Enter the amount from Schedule H, Part I, Line 7c, Column (e).
(26)
Unreimbursed Costs - Other Percent
7C(F)
Enter the percent from Schedule H, Part I, Line 7c, Column (f).
(27)
Financial Assistance Total C
7DC $
Enter the amount from Schedule H, Part I, Line 7d, Column (c).
(28)
Financial Assistance Total D
7DD $
Enter the amount from Schedule H, Part I, Line 7d, Column (d).
(29)
Total Financial Assistance Net Community
7D(E) $
Enter the amount from Schedule H, Part I, Line 7d, Column (e).
(30)
Total Financial Assistance Percent
7D(F)
Enter the percent from Schedule H, Part I, Line 7d, Column (f).
Form 990 - Section 32, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Community Health Improvement C
7EC $
Enter the amount from Schedule H, Part I, Line 7e, Column (c).
(3)
Community Health Improvement D
7ED $
Enter the amount from Schedule H, Part I, Line 7e, Column (d).
(4)
Community Health Improvement E
7EE $
Enter the amount from Schedule H, Part I, Line 7e, Column (e).
(5)
Community Health Improvement Percent
7EF%
Enter the percent from Schedule H, Part I, Line 7e, Column (f).
(6)
Health Professions C
7FC $
Enter the amount from Schedule H, Part I, Line 7f, Column (c).
(7)
Health Professions D
7ED $
Enter the amount from Schedule H, Part I, Line 7f, Column (d).
(8)
Health Professions E
7FE $
Enter the amount from Schedule H, Part I, Line 7f, Column (e).
(9)
Health Professions Percent
7FF%
Enter the percent from Schedule H, Part I, Line 7f, Column (f).
(10)
Subsidized Health Services C
7GC $
Enter the amount from Schedule H, Part I, Line 7g, Column (c).
(11)
Subsidized Health Services D
7GD $
Enter the amount from Schedule H, Part I, Line 7g, Column (d).
(12)
Subsidized Health Services E
7GE $
Enter the amount from Schedule H, Part I, Line 7g, Column (e).
(13)
Subsidized Health Services Percent
7GF%
Enter the percent from Schedule H, Part I, Line 7g, Column (f).
(14)
Research C
7HC $
Enter the amount from Schedule H, Part I, Line 7h, Column (c).
(15)
Research D
7HD $
Enter the amount from Schedule H, Part I, Line 7h, Column (d).
(16)
Research E
7HE $
Enter the amount from Schedule H, Part I, Line 7h, Column (e).
(17)
Research F Percent
7HF%
Enter the percent from Schedule H, Part I, Line 7h, Column (f).
(18)
Cash & Contributions C
7IC $
Enter the amount from Schedule H, Part I, Line 7i, Column (c).
(19)
Cash & Contributions D
7ID $
Enter the amount from Schedule H, Part I, Line 7i, Column (d).
(20)
Cash & Contributions E
7IE $
Enter the amount from Schedule H, Part I, Line 7i, Column (e).
(21)
Cash & Contributions %
7IF%
Enter the percent from Schedule H, Part I, Line 7i, Column (f).
(22)
Total Other Benefits C
7JC $
Enter the amount from Schedule H, Part I, Line 7j, Column (c).
(23)
Total Other Benefits D
7JD $
Enter the amount from Schedule H, Part I, Line 7j, Column (d).
(24)
Total Other Benefits E
7JE $
Enter the amount from Schedule H, Part I, Line 7j, Column (e).
(25)
Total Other Benefits Percent
7JF%
Enter the percent from Schedule H, Part I, Line 7j, Column (f).
(26)
Total C
7KC $
Enter the amount from Schedule H, Part I, Line 7k, Column (c).
(27)
Total D
7KD $
Enter the amount from Schedule H, Part I, Line 7k, Column (d).
(28)
Total E
7KE $
Enter the amount from Schedule H, Part I, Line 7k, Column (e).
(29)
Total Percent
7KF%
Enter the percent from Schedule H, Part I, Line 7k, Column (f).
Form 990 - Section 33, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Net Community
PIII0E $
Enter the amount from Schedule H, Part II, Line 10, Column (e).
(3)
Total Percent of Expense
10F%
Enter the percent from Schedule H, Part II, Line 10 Column (f).
(4)
Report Bad Debt Expense
PT3L1
Enter a yes or no from the yes/no box on Sch H, Part III, Line 1.
(5)
Bad Debt Expense Amount
L2 $
Enter the amount from Schedule H, Part III, Line 2.
(6)
Estimated Bad Debt Expense Amount
L3 $
Enter the amount from Schedule H, Part III, Line 3.
(7)
Revenue from Medicare
L5 $
Enter the amount from Schedule H, Part III, Line 5.
(8)
Medicare Allowable Costs
L6 $
Enter the amount from Schedule H, Part III, Line 6.
(9)
Medicare Surplus or Shortfall
L7 $
Enter the amount from Schedule H, Part III, Line 7.
(10)
Costing Methodology or Source Code
L8CD
Enter the edited code from the right of the boxes from Schedule H, Part III, Line 8.
(11)
Written Debt Collection Policy
L9A
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9a.
(12)
Collection Policy Contain Provision
L9B
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9b.
(13)
Part IV Code
PIVCD
Enter the edited digit from Schedule H, Part IV, right margin.
(14)
Part V How Many Hospital Facilities Did Organization Operate
SECATOP
Enter the number shown in the Hospital Facilities area in the top left portion of Schedule H, Part V, Section A.
(15)
Part V Section C Indicator Code
SECCRM
Enter the indicator code from Schedule H, Part V, Section C, right margin.
(16)
Part V How Many Non-Hospital Facilities Did Organization Operate
SECCTOP
Enter the number from the non-hospital health care benefits line.
(17)
Part V Section D Indicator Code
SECTDRM
Enter the edited code from Schedule H, Part V, Section D, right margin.
Form 990 - Section 34, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 35, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 36, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19d is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 37, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 38, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(25)
Other Similar Actions
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(26)
None of These Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
Form 990 - Section 39, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 40, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 41, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 42, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 43, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 44, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 45, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 46, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 47, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 48, Schedule H (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 49, Schedules L and R (2018)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Excess Benefit Transactions
PT1 RTMAR
Enter the edited digit from the right margin of Schedule L, Part 1.
(3)
Approved by Board or Committee
PT2 RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
(4)
Interest, Annuities, Royalties, Yes/No Box
SCHR PT51A
Enter a yes or a no from the yes/no box from Schedule R, Part V, Line 1a.
Form 990 - Section 01 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section 01 always generates. No entry required.
(2)
Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generated the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4 for procedures.
(3a)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4 for procedures.
(4)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
For a CP 425–431 & 259A-259H, underlined to the right of the Employer ID Number.
See standard rules in IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(5)
Address Check
ADDRESS CHECK?
Enter Y or N as appropriate.
(6)
Street Key
STREET KEY
See IRM 3.24.38
(7)
ZIP Key
ZIP KEY
See IRM 3.24.38
(8)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under title of form.
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
For a CP 425–431 & 259A-259H, edited in the area around the Tax Period.
(9)
In Care of Name Line
C/O NAME
Enter the in-care-of name, if shown.
Note:¶
Downstream processing generates the (%) sign.
(10)
Foreign Address
FGN ADD
Enter the foreign street address, if shown.
See IRM 3.24.38 for additional instructions.
(11)
Street Address
ADDR
Enter the street address from the address line.
See IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information, even if prompted to do so. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(12)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country code.
(13)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.).
(14)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
(15)
Group Code H(b)
BOXHB
Enter a 1 or 2 from the yes/no box from the entity area of the return, Line H(b). For a CP425–431 & 259A-259H, press
(16)
Tax Exempt Status
BOXI
Enter the edited two digit code from the blank space of Box I.
(17)
Type of Organization
BOXK RT
Enter the edited code from the blank space of Box K. For a CP 425–431 & 259A-259H always enter a 9.
(18)
Computer Condition Codes
CCC
Enter the edited characters as shown on dotted portion of Lines 2–7b. For a 420–431 & 259A-259H, enter the edited characters as shown in the center of the return. If a Condition Code is illegible, enter a # in its place.
(19)
Return Processing Code
01RPC
Enter the edited codes on Page 1, in the right margin next to line 1.
(20)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM 3.24.38 for special instructions.
If a "G" Condition Code is present and the return is non-remittance, end the document after this element.
If a CP 425–431 & 259A-259H, end the document after this element.
(21)
Preparation Code
PREP
Enter the edited code from the right of the preparer PTIN Line.
(22)
Preparer PTIN
PTIN
Enter the Preparer's PTIN.
(23)
Preparer's EIN
PEIN
Enter the preparer's EIN.
(24)
Preparer Telephone #
TEL#
Enter the preparer phone number.
If the Type of Organization is a ""9" " , and the ""9" is underlined" , don't end the document. Continue transcribing the return.
If Type of Organization is a "9" , and the "9" is NOT underlined, press
(25)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and the return is a remittance, Press
If the Type of Organization is "9" from Section 01 E–10 and the "" 9" is underlined" , do NOT end the document. Continue processing the return.
If the Type of Organization is "9" , and the "9" is NOT underlined, press
Form 990 - Section 02 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800
(3)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(4)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(5)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800, in MMDDYY format.
For special instructions, see IRM 3.24.38.
(6)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990 - Section 03 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return, ONLY if underlined in green.
(3)
IRI Codes
PG2TOP
Enter the edited digits from the top of page 2.
(4)
Undertake New Activities Y/N
L2
Enter a yes or no from the yes/no box from Part III, Line 2.
(5)
Make Significant Changes Y/N
L3
Enter a yes or no from the yes/no box from Part III, Line 3.
(6)
Exempt Purpose Code 1
L4A
Press Enter only. Don't transcribe a code.
(7)
Exempt Purpose Code 2
L4B
Press Enter only. Don't transcribe a code.
(8)
Exempt Purpose Code 3
L4C
Press Enter only. Don't transcribe a code.
(9)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
Note:¶
If a "D1" is edited and underlined, pick up as an alpha "D" and numeric "1" . Don't confuse with an alpha "D" and alpha "I" .
(10)
501(c)(3) or 4947(a)(1) Y/N
L1
Enter a yes or no from the yes/no box from Part IV, Line 1.
(11)
Required to Complete Sch B Y/N
L2
Enter a yes or no from the yes/no box from Part IV, Line 2.
(12)
Engage in Direct or Indirect Political Y/N
L3
Enter a yes or no from the yes/no box from Part IV, Line 3.
(13)
Engage in Lobbying Activities Y/N
L4
Enter a yes or no from the yes/no box from Part IV, Line 4.
(14)
Subject to Sec 6033(c) Notice
L5
Enter a yes or no from the yes/no box from Part IV, Line 5.
(15)
Maintain Donor Advised Y/N
L6
Enter a yes or no from the yes/no box from Part IV, Line 6.
(16)
Receive or Hold Conservation Y/N
L7
Enter a yes or no from the yes/no box from Part IV, Line 7.
(17)
Maintain Collections of Works of Art Y/N
L8
Enter a yes or no from the yes/no box from Part IV, Line 8.
(18)
Provide Credit Counseling Y/N
L9
Enter a yes or no from the yes/no box from Part IV, Line 9.
(19)
Hold Assets in Term/Permanent Y/N
L10
Enter a yes or no from the yes/no box from Part IV, Line 10.
(20)
Land, Buildings, Equipment
11A
Enter a yes or no from the yes/no box from Part IV, Line 11a.
(21)
Investments Other Securities
11B
Enter a yes or no from the yes/no box from Part IV, Line 11b.
(22)
Investments Program Related
11C
Enter a yes or no from the yes/no box from Part IV, Line 11c.
(23)
Other Assets
11D
Enter a yes or no from the yes/no box from Part IV, Line 11d.
(24)
Other Liabilities
11E
Enter a yes or no from the yes/no box from Part IV, Line 11e.
(25)
Separate or Consolidated Financial Statements
11F
Enter a yes or no from the yes/no box from Part IV, Line 11f.
(26)
Separate Independent Audited Financial
12A
Enter a yes or no from the yes/no box from Part IV, Line 12a.
(27)
Consolidated Independent Financial
12B
Enter a yes or no from the yes/no box from Part IV, Line 12b.
(28)
School Described in 170(b)(1)(A)(ii)
L13
Enter a yes or no from the yes/no box from Part IV, Line 13.
(29)
Maintain an Office, etc Outside U.S.
14A
Enter a yes or no from the yes/no box from Part IV, Line 14a.
(30)
Have Aggregate Revenues/Expenses
14B
Enter a yes or no from the yes/no box from Part IV, Line 14b.
(31)
Report > $5000 on Part IX Organizations
L15
Enter a yes or no from the yes/no box from Part IV, Line 15.
(32)
Report > $5000 on Part IX Individuals
L16
Enter a yes or no from the yes/no box from Part IV, Line 16.
(33)
Report > $15,000 on Part IX, Line 11e
L17
Enter a yes or no from the yes/no box from Part IV, Line 17.
(34)
Report > $15,000 on Part VIII, Line 1c/8a
L18
Enter a yes or no from the yes/no box from Part IV, Line 18.
(35)
Report > $15,000 on Part VIII, Line 9a
L19
Enter a yes or no from the yes/no box from Part IV, Line 19.
(36)
Operate Hospitals
20A
Enter a yes or no from the yes/no box from Part IV, Line 20a.
(37)
Attach Audited Financial Statements
20B
Enter a yes or no from the yes/no box from Part IV, Line 20b.
Form 990 - Section 04 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Report > $5000 on Part IX, Line 1
L21
Enter a yes or no from the yes/no box from Part IV, Line 21.
(3)
Report > $5000 on Part IX, Line 2
L22
Enter a yes or no from the yes/no box from Part IV, Line 22.
(4)
Answer Yes to Questions 3, 4, 5
L23
Enter a yes or no from the yes/no box from Part IV, Line 23.
(5)
Any Tax-Exempt Bond with Outstanding Principal
24A
Enter a yes or no from the yes/no box from Part IV, Line 24a.
(6)
Invest Any Proceeds
24B
Enter a yes or no from the yes/no box from Part IV, Line 24b.
(7)
Maintain an Escrow Account
24C
Enter a yes or no from the yes/box from Part IV, Line 24c.
(8)
Act as On Behalf Of Issuer
24D
Enter a yes or no from the yes/no box from Part IV, Line 24d.
(9)
501(c)(3) / 501(c)(4) Organizations
25A
Enter a yes or no from the yes/no box from Part IV, Line 25a.
(10)
Become Aware it Engaged in Excess
25B
Enter a yes or no from the yes/no box from Part IV, Line 25b.
(11)
Loan to/by Current/Former Officer
L26
Enter a yes or no from the yes/no box from Part IV, Line 26.
(12)
Provide Grant or Other Assistance
L27
Enter a yes or no from the yes/no box from Part IV, Line 27.
(13)
Business Transaction with Current or Former Officer
28A
Enter a yes or no from the yes/no box from Part IV, Line 28a.
(14)
Business Transaction with Family Member
28B
Enter a yes or no from the yes/no box from Part IV, Line 28b.
(15)
Business Transaction with Entity of Current/ Former Officer
28C
Enter a yes or no from the yes/no box from Part IV, Line 28c.
(16)
Receive or Accrue > $25,000 in Non-Cash
L29
Enter a yes or no from the yes/no box from Part IV, Line 29.
(17)
Receive or Accrue Contributions of Art
L30
Enter a yes or no from the yes/no box from Part IV, Line 30.
(18)
Liquidate, Terminate, Dissolve
L31
Enter a yes or no from the yes/no box from Part IV, Line 31.
(19)
Sell, Exchange, Dispose
L32
Enter a yes or no from the yes/no box from Part IV, Line 32.
(20)
Own 100% of an Entity
L33
Enter a yes or no from the yes/no box from Part IV, Line 33.
(21)
Related to Tax-Exempt / Taxable Entity
L34
Enter a yes or no from the yes/no box from Part IV, Line 34.
(22)
Controlled Entity Within 512(b)(13)
L35A
Enter a yes or no from the yes/no box from Part IV, Line 35a.
23
Receive Payment or Engage Transaction Within
35B
Enter a yes or no from the yes/no box from Part IV, Line 35b.
(24)
Make Any Transfers
L36
Enter a yes or no from the yes/no box from Part IV, Line 36.
(25)
Conduct More than 5%
L37
Enter a yes or no from the yes/no box from Part IV, Line 37.
(26)
Complete Schedule O
L38
Enter a yes or no from the yes/no box from Part IV, Line 38.
Form 990 - Section 05 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part V Number of Forms/1096
PTVL1A
Enter the number shown on Part V, Line 1a.
(3)
Number of Forms W-2G
L1B
Enter the number shown on Part V, Line 1b.
(4)
Comply with Backup Withholding Rules
L1C
Enter a yes or no from the yes/no box from Part V, Line 1c.
(5)
Number of Employees / W-3
L2A
Enter the number shown on Part V, Line 2a.
(6)
File All Required Federal Employment Returns
L2B
Enter a yes or no from the yes/no box from Part V, Line 2b.
(7)
Unrelated Business Income > $1000
L3A
Enter a yes or no from the yes/box from Part V, Line 3a.
(8)
If Yes, Has Filed a 990-T
L3B
Enter a yes or no from the yes/no box from Part V, Line 3b.
(9)
Interest in or a Signature
L4A
Enter a yes or no from the yes/no box from Part V, Line 4a.
(10)
Party to a Prohibited Tax Shelter
L5A
Enter a yes or no from the yes/no box from Part V, Line 5a.
(11)
Taxable Party Notify Organization
L5B
Enter a yes or no from the yes/no box from Part V, Line 5b.
(12)
If Yes, Did Organization File 8886-T
L5C
Enter a yes or no from the yes/no box from Part V, Line 5c.
(13)
Annual Gross Receipts Normally >$100,000
L6A
Enter a yes or no from the yes/no box from Part V, Line 6a.
(14)
If Yes, Did Organization Include
L6B
Enter a yes or no from the yes/no box from Part V, Line 6b.
(15)
$75 Partly Contribution/Goods/Services
L7A
Enter a yes or no from the yes/no box from Part V, Line 7a.
(16)
If Yes, Did Organization Notify Donor
L7B
Enter a yes or no from the yes/no box from Part V, Line 7b.
(17)
Sell, Exchange, Otherwise Dispose
L7C
Enter a yes or no from the yes/no box from Part V, Line 7c.
(18)
Number of Forms 8282
L7D
Enter the number shown on Part V, Line 7d.
(19)
Receive Any Funds
L7E
Enter a yes or no from the yes/no box from Part V, Line 7e.
(20)
Pay Premiums
L7F
Enter a yes or no from the yes/no box from Part V, Line 7f.
(21)
Contributions of Qualified Intellectual Property
L7G
Enter a yes or no from the yes/no box from Part V, Line 7g.
(22)
Contributions of Cars, Boats, Airplanes
L7H
Enter a yes or no from the yes/no box from Part V, Line 7h.
(23)
Sponsoring Orgs, 509(a)(3) Excess Business Holdings
L8
Enter a yes or no from the yes/no box from Part V, Line 8.
(24)
Make Taxable Distributions Under 4966
L9A
Enter a yes or no from the yes/no box from Part V, Line 9a.
(25)
Make Distribution to Donor
L9B
Enter a yes or no from the yes/no box from Part V, Line 9b.
(26)
Initiation Fees/Capital Contributions
10A $
Enter the amount from Part V, Line 10a.
(27)
Gross Receipts for Public Use of Facilities
10B $
Enter the amount from Part V, Line 10b.
(28)
Gross Income/Members/Shareholders
11A $
Enter the amount from Part V, Line 11a.
(29)
Gross Income from Other Sources
11B $
Enter the amount from Part V, Line 11b.
(30)
4947(a)(1) Filing 990 in Lieu of 1041
12A
Enter a yes or no from the yes/no box from Part V, Line 12a.
(31)
Amount of Tax Exempt Interest
12B $
Enter the amount from Part V, Line 12b.
(32)
Licensed to Issue Qualified Health Plans
13A
Enter a yes or no from the yes/no box from Part V, Line 13a.
(33)
Aggregate Amount of Reserves to Maintain
13B $
Enter the amount from Part V, Line 13b.
(34)
Aggregate Amount of Reserves on Hand
13C $
Enter the amount from Part V, Line 13c.
(35)
Receive Payments for Indoor Tanning
14A
Enter a yes or no from the yes/no box from Part V, Line 14a.
(36)
Filed Form 720 to Report Payments
14B
Enter a yes or no from the yes/no box from Part V, Line 14b.
(37)
Subject to Section 4960 Tax on Payments of More Than $1,000,000
15
Enter 1 for yes and 2 for no Part V, Line 15.
(38)
Education Institution Subject to 4968 Excise Tax
16
Enter 1 for yes and 2 for no Part V, Line 16.
Form 990 - Section 06 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Voting Members of Governing Body
PG6L1A
Enter the number shown on Part VI, Section A, Line 1a.
(3)
Independent Voting Members
L1B
Enter the number shown on Part VI, Section A, Line 1b.
(4)
Officer, Director, Trustee Family/Relationship
L2
Enter a yes or no from the yes/no box from Part VI, Section A, Line 2.
(5)
Delegate Control Over Management
L3
Enter a yes or no from the yes/no box from Part VI, Section A, Line 3.
(6)
Make Significant Changes
L4
Enter a yes or no from the yes/no box from Part VI, Section A, Line 4.
(7)
Become Aware of Material Diversion
L5
Enter a yes or no from the yes/box from Part VI, Section A, Line 5.
(8)
Members of Stockholders
L6
Enter a yes or no from the yes/no box from Part VI, Section A, Line 6.
(9)
Members, Stockholders, Other Persons
7A
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7a.
(10)
Members Subject to Approval
7B
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7b.
(11)
Determining Compensation for CEO, Exec Director
15A
Enter a yes or no from the yes/no box from Part VI, Section B, Line 15a.
(12)
Reportable Compensation from the Organization 1
PTVII1D $
Enter the amount from Part VII Section A, Line 1, Column (d).
(13)
Reportable Compensation from Related Organizations 1
PTVII1E $
Enter the amount from Part VII Section A, Line 1, Column (e).
(14)
Estimated Amount of Other Compensation 1
PTVII1F $
Enter the amount from Part VII Section A, Line 1, Column (f).
(15)
Reportable Compensation from the Organization 2
PTVII2D $
Enter the amount from Part VII Section A, Line 2, Column (d).
(16)
Reportable Compensation from Related Organizations 2
PTVII2E $
Enter the amount from Part VII Section A, Line 2, Column (e).
(17)
Estimated Amount of Other Compensation 2
PTVII2F $
Enter the amount from Part VII Section A, Line 2, Column (f).
(18)
Reportable Compensation from the Organization 3
PTVII3D $
Enter the amount from Part VII Section A, Line 3, Column (d).
(19)
Reportable Compensation from Related Organizations 3
PTVII3E $
Enter the amount from Part VII Section A, Line 3, Column (e).
(20)
Estimated Amount of Other Compensation 3
PTVII3F $
Enter the amount from Part VII Section A, Line 3, Column (f).
(21)
Reportable Compensation from the Organization 4
PTVII4D $
Enter the amount from Part VII Section A, Line 4, Column (d).
(22)
Reportable Compensation from Related Organizations 4
PTVII4E $
Enter the amount from Part VII Section A, Line 4, Column (e).
(23)
Estimated Amount of Other Compensation 4
PTVII4F $
Enter the amount from Part VII Section A, Line 4, Column (f).
(24)
Reportable Compensation from the Organization 5
PTVII5D $
Enter the amount from Part VII Section A, Line 5, Column (d).
(25)
Reportable Compensation from Related Organizations 5
PTVII5E $
Enter the amount from Part VII Section A, Line 5, Column (e).
(26)
Estimated Amount of Other Compensation 5
PTVII5F $
Enter the amount from Part VII Section A, Line 5, Column (f).
(27)
Total Reportable Compensation from Organization
PG8L1D(D) $
Enter the amount from Part VII, Section A, Line 1d, Column D.
(28)
Total Reportable Compensation from Related Organization
1D(E) $
Enter the amount from Part VII, Section A, Line 1d, Column E.
(29)
Total Compensation from Organization & Related Organizations
1D(F) $
Enter the amount from Part VII, Section A, Line 1d, Column F.
(30)
Total Individuals who Received > $100,000
SECTAL2
Enter the number shown on Part VII, Section A, Line 2.
(31)
Total Independent Contractors Received > $100,000
SECTBL2
Enter the number shown on Part VII, Section B, Line 2.
Form 990 - Section 07 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Contributions/ Gifts/Grants
PG9L1H $
Enter the amount from Part VIII, Line 1h, Column (A).
(3)
Program Service Business Code 2A
2ACODE
Enter the number shown on Part VIII, Line 2a.
(4)
2a Program Service Revenue Col. A
2A(A) $
Enter the amount from Part VIII, Line 2a, Column (A).
(5)
Program Service Business Code 2B
2BCODE
Enter the number shown on Part VIII, Line 2b.
(6)
2b Program Service Revenue Col. A
2B(A) $
Enter the amount from Part VIII, Line 2b, Column (A).
(7)
Program Service Business Code 2C
2CCODE
Enter the number shown on Part VIII, Line 2c.
(8)
2c Program Service Revenue Col. A
2C(A) $
Enter amount shown on Part VIII, Line 2c, Column (A).
(9)
Program Service Business Code 2D
2DCODE
Enter the number shown on Part VIII, Line 2d.
(10)
2d Program Service Revenue Col. A
2D(A) $
Enter amount shown on Part VIII, Line 2d, Column (A).
(11)
Program Service Business Code 2E
2ECODE
Enter the number shown on Part VIII, Line 2e.
(27)
2e Program Service Revenue Col. A
2E(A) $
Enter the amount from Part VIII, Line 2e, Column (A).
(28)
2f Program Service Revenue Col. A
2F(A) $
Enter the amount from Part VIII, Line 2f, Column (A).
(29)
2g Program Service Revenue Total Col. A
2GTOT $
Enter the amount from Part VIII, Line 2g, Column (A).
(15)
Investment Income Col. A
3(A) $
Enter the amount from Part VIII, Line 3, Column (A).
(16)
Tax-Exempt Bond Proceeds Col. A
4(A) $
Enter the amount from Part VIII, Line 4, Column (A).
(17)
Royalties Col. A
5(A) $
Enter the amount from Part VIII, Line 5, Column (A).
(18)
Gross Rents Real
6(A)I $
Enter the amount from Part VIII, Line 6a, Column (i).
(19)
Gross Rents Personal
6(A)II $
Enter the amount from Part VIII, Line 6a, Column (ii).
(20)
Rental Expenses Real
6(B)(I) $
Enter the amount from Part VIII, Line 6b, Column (i).
(21)
Rental Expenses Personal
6(B)(II) $
Enter the amount from Part VIII, Line 6b, Column (ii).
(22)
Rental Income/Loss Real
6C(I) $
Enter the amount from Part VIII, Line 6c, Column (i).
(23)
Rental Income/Loss Personal
6C(II) $
Enter the amount from Part VIII, Line 6c, Column (ii).
(24)
Net Rental Income/Loss Col. A
6D(A) $
Enter the amount from Part VIII, Line 6d, Column (A).
Form 990 - Section 08 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross Amount from Sales of Assets - Securities
PG9L7A(I) $
Enter the amount from Part VIII, Line 7a, Column (i).
(3)
Gross Amount from Sales of Assets - Other
7A(II) $
Enter the amount from Part VIII, Line 7a, Column (ii).
(4)
Cost or Other Basis/Sales - Securities
7B(I) $
Enter the amount from Part VIII, Line 7b, Column (i).
(5)
Cost or Other Basis/Sales - Other
7B(II) $
Enter the amount from Part VIII, Line 7b, Column (ii).
(6)
Gain/Loss - Securities
7C(I) $
Enter the amount from Part VIII, Line 7c, Column (i).
(7)
Gain/Loss - Other
7C(II) $
Enter the amount from Part VIII, Line 7c, Column (ii).
(8)
Net Gain/Loss Col. A
7D(A) $
Enter the amount from Part VIII, Line 7d, Column (A).
(9)
Gross Income from Fundraising
8A $
Enter the amount from Part VIII, Line 8a.
(10)
Less Direct Expenses 8b
8B $
Enter the amount from Part VIII, Line 8b.
(11)
Net Income/Loss from Fundraising Col. A
8C(A) $
Enter the amount from Part VIII, Line 8c, Column (A).
(12)
Gross Income from Gaming
9A $
Enter the amount from Part VIII, Line 9a.
(13)
Less Direct Expenses 9b
9B $
Enter the amount from Part VIII, Line 9b.
(14)
Net Income/Loss from Gaming
9C(A) $
Enter the amount from Part VIII, Line 9c, Column (A).
(15)
Gross Sales of Inventory
10A $
Enter the amount from Part VIII, Line 10a.
(16)
Less Cost of Goods Sold
10B $
Enter the amount from Part VIII, Line 10b.
(17)
Net Income/Loss from Sales Col. A
10C(A) $
Enter the amount from Part VIII, Line 10c, Column (A).
(18)
Misc. Revenue Business Code 11a
11ACODE
Enter the number shown on Part VIII, Line 11a.
(19)
Misc. Revenue Total (A) Col. A
11A(A) $
Enter the amount from Part VIII, Line 11a, Column (A).
(20)
Misc. Revenue Business Code 11b
11BCODE
Enter the number shown on Part VIII, Line 11b.
(21)
Misc. Revenue Total 11B(A) Col. A
11B(A) $
Enter the amount from Part VIII, Line 11b, Column (A).
(22)
Misc. Revenue Business Code 11c
11CCODE
Enter the number shown on Part VIII, Line 11c.
(23)
Misc. Revenue Total 11C(A) Col. A
11C(A) $
Enter the amount from Part VIII, Line 11c, Column (A).
(24)
Misc. Revenue Total 11D(A) Col. A
11D(A) $
Enter the amount from Part VIII, Line 11d, Column (A).
(25)
Misc. Revenue Total 11E Col. A
11ETOT $
Enter the amount from Part VIII, Line 11e, Column (A).
(26)
Total Revenue 12(A) Col. A
12(A) $
Enter the amount from Part VIII, Line 12, Column (A).
Form 990 - Section 09 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross to Government / Organizations in U.S.
PG10L1(A) $
Enter the amount from Part IX, Line 1, Column (A).
(3)
Grants / Other Assistance in U.S.
L2(A) $
Enter the amount from Part IX, Line 2, Column (A).
(4)
Grants / Other Assistance Outside U.S.
L3(A) $
Enter the amount from Part IX, Line 3, Column (A).
(5)
Benefits Paid to / for Members
L4(A) $
Enter the amount from Part IX, Line 4, Column (A).
(6)
Compensation of Current Officers / Directors
L5(A) $
Enter the amount from Part IX, Line 5, Column (A).
(7)
Compensation to Disqualified Persons
L6(A) $
Enter the amount from Part IX, Line 6, Column (A).
(8)
Other Salaries / Wages
L7(A) $
Enter the amount from Part IX, Line 7, Column (A).
(9)
Pension Plan Contributions
L8(A) $
Enter the amount from Part IX, Line 8, Column (A).
(10)
Other Employee Benefits
L9(A) $
Enter the amount from Part IX, Line 9, Column (A).
(11)
Payroll Taxes
10(A) $
Enter the amount from Part IX, Line 10, Column (A).
(12)
Fees for Services / Management
11A(A) $
Enter the amount from Part IX, Line 11a, Column (A).
(13)
Fees for Services / Legal
11B(A) $
Enter the amount from Part IX, Line 11b, Column (A).
(14)
Fees for Services / Accounting
11C(A) $
Enter the amount from Part IX, Line 11c, Column (A).
(15)
Fees for Services / Lobbyists
11D(A) $
Enter the amount from Part IX, Line 11d, Column (A).
(16)
Fees for Services / Professional Fundraising
11E(A) $
Enter the amount from Part IX, Line 11e, Column(A).
(17)
Fees for Services / Investment Management
11F(A) $
Enter the amount from Part IX, Line 11f, Column (A).
(18)
Fees for Services / Other
11G(A) $
Enter the amount from shown on Part IX, Line 11g, Column (A).
(19)
Advertising / Promotion
12(A) $
Enter the amount from Part IX, Line 12, Column (A).
(20)
Office Expenses
13(A) $
Enter the amount from on Part IX, Line 13, Column (A).
(21)
Information Technology
14(A) $
Enter the amount from Part IX, Line 14, Column (A).
(22)
Royalties
15(A) $
Enter the amount from Part IX, Line 15, Column (A).
(23)
Occupancy
16(A) $
Enter the amount from Part IX, Line 16, Column (A).
(24)
Travel
17(A) $
Enter the amount from Part IX, Line 17, Column (A).
(25)
Payments of Travel / Entertainment
18(A) $
Enter the amount from Part IX, Line 18, Column (A).
(26)
Conferences, Conventions / Meetings
19(A) $
Enter the amount from Part IX, Line 19, Column (A).
(27)
Interest
20(A) $
Enter the amount from Part IX, Line 20, Column (A).
(28)
Payments to Affiliates
21(A) $
Enter the amount from Part IX, Line 21, Column (A).
(29)
Depreciation / Depletion
22(A) $
Enter the amount from Part IX, Line 22, Column (A).
(30)
Insurance
23(A) $
Enter the amount from Part IX, Line 23, Column (A).
(31)
Other Expenses a
24A(A) $
Enter the amount from Part IX, Line 24a, Column (A).
(32)
Other Expenses b
24B(A) $
Enter the amount from Part IX, Line 24b, Column (A).
(33)
Other Expenses c
24C(A) $
Enter the amount from Part IX, Line 24c, Column (A).
(34)
Other Expenses d
24D(A) $
Enter the amount from Part IX, Line 24d, Column (A).
(35)
Other Expenses e
24E(A) $
Enter the amount from Part IX, Line 24e, Column (A).
(36)
NA
24F(A) $
Enter only.
(37)
Total Functional Expenses
25(A) $
Enter the amount from Part IX, Line 25, Column (A).
Form 990 - Section 10 (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash EOY
PG11L1(B) $
Enter the amount from Part X, Line 1, Column (B).
(3)
Savings / Temporary Investments EOY
L2(B) $
Enter the amount from Part X, Line 2, Column (B).
(4)
Pledges / Grants Receivable EOY
L3(B) $
Enter the amount from Part X, Line 3, Column (B).
(5)
Accounts Receivable EOY
L4(B) $
Enter the amount from Part X, Line 4, Column (B).
(6)
Receivables from Current / Former EOY
L5(B) $
Enter the amount from Part X, Line 5, Column (B).
(7)
Receivables from Disqualified Persons EOY
L6(B) $
Enter the amount from Part X, Line 6, Column (B).
(8)
Notes / Loans Receivable EOY
L7(B) $
Enter the amount from Part X, Line 7, Column (B).
(9)
Inventories for Sale EOY
L8(B) $
Enter the amount from Part X, Line 8, Column (B).
(10)
Prepaid Expenses EOY
L9(B) $
Enter the amount from Part X, Line 9, Column (B).
(11)
Land / Buildings Less Accumulated EOY
10C(B) $
Enter the amount from Part X, Line 10c, Column (B).
(12)
Investments Publicly Traded Securities EOY
11(B) $
Enter the amount from Part X, Line 11, Column (B).
(13)
Investments Other Securities EOY
12(B) $
Enter the amount from Part X, Line 12, Column (B).
(14)
Investments Program Related EOY
13(B) $
Enter the amount from Part X, Line 13, Column (B).
(15)
Intangible Assets EOY
14(B) $
Enter the amount from Part X, Line 14, Column (B).
(16)
Other Assets EOY
15(B) $
Enter the amount from Part X, Line 15, Column(B).
(17)
Total Assets BOY
16(A) $
Enter the amount from Part X, Line 16, Column (A).
(18)
Total Assets EOY
16(B) $
Enter the amount from shown on Part X, Line 16, Column (B).
(19)
Accounts Payable EOY
17(B) $
Enter the amount from Part X, Line 17, Column (B).
(20)
Grants Payable EOY
18(B) $
Enter the amount from on Part X, Line 18, Column (B).
(21)
Deferred Revenue EOY
19(B) $
Enter the amount from Part X, Line 19, Column (B).
(22)
Tax-Exempt Bond Liabilities EOY
20(B) $
Enter the amount from Part X, Line 20, Column (B).
(23)
Escrow Liability EOY
21(B) $
Enter the amount from Part X, Line 21, Column (B).
(24)
Payable to Current / Former Officers EOY
22(B) $
Enter the amount from Part X, Line 22, Column (B).
(25)
Secured Mortgages / Notes EOY
23(B) $
Enter the amount from Part X, Line 23, Column (B).
(26)
Unsecured Notes / Loans EOY
24(B) $
Enter the amount from Part X, Line 24, Column (B).
(27)
Other Liabilities EOY
25(B) $
Enter the amount from Part X, Line 25, Column (B).
(28)
Total Liabilities BOY
26(A) $
Enter the amount from Part X, Line 26, Column (A).
(29)
Total Liabilities EOY
26(B) $
Enter the amount from Part X, Line 26, Column (B).
(30)
Net Assets Without Restrictions
27(B) $
Enter the amount from Part X, Line 27, Column (B).
(31)
Net assets with donor restrictions
28(B) $
Enter the amount from Part X, Line 28, Column (B).
(33)
Capital Stock / Trust EOY
29(B) $
Enter the amount from Part X, Line 29, Column (B).
(34)
Paid-In / Capital Surplus EOY
30(B) $
Enter the amount from Part X, Line 30, Column (B).
(35)
Retained Earnings, Endowment EOY
31(B) $
Enter the amount from Part X, Line 31, Column (B).
(36)
Total Net Assets or Fund Balances EOY
32(B) $
Enter the amount from Part X, Line 32, Column (B).
(37)
Total Net Assets or Fund Balances BOY
33(A) $
Enter the amount from Part X, Line 33, Column (A).
(38)
N/A
33(B) $
N/A
Press enter only.
Form 990 - Section 11, Schedule A (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Type of Organization
L11
Enter one of the following from Line 12:
1 = Type I,
2 = Type II,
3 = Type III – Functionally integrated
4 = Type III – Non-functionally integrated Blank
If more than one box is checked, enter the corresponding number for the first box checked.
(4)
Type I, II or III Supporting Organization
11E
Enter a 1 if the box is checked on Schedule A, Part I, Line 12e.
(5)
Number of Supported Organizations
11F
Enter the number from Line 12f.
(6)
EIN A
12G(II)A
Enter the EIN in Part I, Line 12g, Row A, Column (ii).
(7)
Type of Org A
12G(III)A
Enter the type of organization in Part I, Line 12g, Row A, Column (iii).
(8)
Listed in Governing Doc A
12G(IV)A
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row A, Column (iv).
(9)
Amount of Support A
12G(V) A $
Enter the amount on Part I, Line 12g, Row A, Column (v).
(10)
EIN B
12G(II)B
Enter the EIN in Part I, Line 12g, Row B, Column (ii).
(11)
Type of Org B
12G(III)B
Enter the type of organization in Part I, Line 12g, Row B, Column (iii).
(12)
Listed in Governing Doc B
12G(IV)B
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row B, Column (iv).
(13)
Amount of Support B
12G(V)B $
Enter the amount Part I, Line 12g, Row B, Column (v).
(14)
EIN C
12G(II)C
Enter the EIN in Part I, Line 12g, Row C, Column (ii).
(15)
Type of Org C
12G(III)C
Enter the type of organization in Part I, Line 12g, Row C, Column (iii).
(16)
Listed in Governing Doc C
12G(IV)C
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row C, Column (iv).
(17)
Amount of Support C
12G(V)C $
Enter the amount on Part I, Line 12g, Row C, Column (v).
(18)
EIN D
12G(II)D
Enter the EIN in Part I, Line 12g, Row D, Column (ii).
(19)
Type of Org D
12G(III)D
Enter the type of organization in Part I, Line 12g, Row D, Column (iii).
(20)
Listed in Governing Doc D
12G(IV)D
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row D, Column (iv).
(21)
Amount of Support D
12G(V)D $
Enter the amount on Part I, Line 12g, Row D, Column (v).
(22)
EIN E
12G(II)E
Enter the EIN in Part I, Line 12g, Row E, Column (ii).
(23)
Type of Org E
12G(III)E
Enter the type of organization in Part I, Line 12g, Row E, Column (iii).
(24)
Listed in Governing Doc E
12G(IV)E
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row E, Column (iv).
(25)
Amount of Support E
12G(V)E $
Enter the amount on Part I, Line 12g, Row E, Column (v).
(26)
Filling Field
N/A
Blank field generated on output.
(27)
Total Number of Organizations
12G(I)TOT
Enter the number from Schedule A, Part I, Line 12g, Column (i), Total Line.
(28)
Total Amount of Support
GVTOT $
Enter the amount on Part I, Line 12g, Total, Column (v).
(29)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(30)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(31)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(32)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(33)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(34)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(35)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(36)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(37)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(38)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(39)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(40)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(41)
First 5 Years Checkbox
13CKBX
Enter a 1 if the box on Schedule A, Part II, Line 13 is checked.
(42)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter a 1 if the box on Schedule A, Part II, Line 16a is checked.
(43)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter a 1 if the box on Schedule A, Part II, Line 16b is checked.
(44)
10% Facts & Circumstances Current
17ACKBX
Enter a 1 if the box on Schedule A, Part II, Line 17a is checked.
(45)
10% Facts & Circumstances Prior
17BCKBX
Enter a 1 if the box on Schedule A, Part II, Line 17b is checked.
(46)
Private Foundation Checkbox
18CKBX
Enter a 1 if the box on Schedule A, Part II, Line 18 is checked.
Form 990 - Section 12, Schedule A (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter a 1 if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter a 1 if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter a 1 if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter a 1 if the box on Schedule A, Part III, Line 20 is checked.
(23)
Part IV Section A Data Present Indicator
PTIVA
Enter a 1 if data is present in Part IV, Section A.
(24)
Part IV Section B Data Present Indicator
PTIVB
Enter a 1 if data is present in Part IV, Section B.
(25)
Part IV Section C Data Present Indicator
PTIVC
Enter a 1 if data is present in Part IV, Section C.
(26)
Part IV Section D Data Present Indicator
PTIVD
Enter a 1 if data is present in Part IV, Section D.
(27)
Part IV Section E Data Present Indicator
PTIVE
Enter a 1 if data is present in Part IV, Section E.
(28)
Filling Field
N/A
Generates a blank field on output.
(29)
Excess Distributions C
PTVE3C $
Enter the amount from Part V, Section E, Line 3c.
(30)
Excess Distributions D
PTVE3D $
Enter the amount from Part V, Section E, Line 3d.
(31)
Excess Distributions E
PTVE3E $
Enter the amount from Part V, Section E, Line 3e.
(32)
Excess Distributions Breakdown B
PTVE8B $
Enter the amount from Part V, Section E, Line 8b.
(33)
Excess Distributions Breakdown C
PTVE8C $
Enter the amount from Part V, Section E, Line 8c.
(34)
Excess Distributions Breakdown D
PTVE8D $
Enter the amount from Part V, Section E, Line 8d.
(35)
Excess Distributions Breakdown E
PTVE8E $
Enter the amount from Part V, Section E, Line 8e.
Form 990 - Section 13, Schedules C & D (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHIAL2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Total Number at EOY
SCHDL1(A)
Enter the number shown on Schedule D, Part I, Line 1, Column (a).
(4)
Contributions To
L2(A) $
Enter the amount from Schedule D, Part I, Line 2, Column (a).
(5)
Grants From
L3(A) $
Enter the amount from Schedule D, Part I, Line 3, Column (a).
(6)
Aggregate Value
L4(A) $
Enter the amount from Schedule D, Part I, Line 4, Column (a).
(7)
Inform All Donors Checkbox
L5
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 5.
(8)
Inform All Grantees Checkbox
L6
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 6.
Form 990 - Section 31, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Financial Assistance
L1A
Enter the following from the checkbox Schedule H, Part I, Line 1a:
1 = yes
2 = no.
(3)
Written Policy
L1B
Enter the following from the checkbox Schedule H, Part I, Line 1b:
1 = yes
2 = no.
(4)
Best Describes
L2
Enter the following:
1 = Applied Uniformly to all.
2 = Applied Uniformly to most.
3 = Generally tailored.
(5)
FPG Used
L3A
Enter the following from the checkbox Schedule H, Part I, Line 3a:
1 = yes
2 = no.
(6)
FPG%
L3A%
Enter the percent that is next to the marked box from Schedule H, Part I, Line 3a percent:
1 = 100%
2 = 150%
3 = 200%
4 = Other.
(7)
FPG Discounted Care
L3B
Enter the following from the checkbox Schedule H, Part I, Line 3b:
1 = yes
2 = no.
(8)
FPG Discounted Care %
L3B%
Enter the percent that is next to the marked box from Schedule H, Part I, Line 3b percent:
1 = 200%
2 = 250%
3 = 300%
4 = 350%
5 = 400%
6 = Other
If more than one box is checked, enter the number for the largest percent.
(9)
Applied to Largest Number of Patients
L4
Enter the following from the checkbox Schedule H, Part I, Line 4:
1 = yes
2 = no.
(10)
Budget Amounts for Free or Discounted
L5A
Enter the following from the checkbox Schedule H, Part I, Line 5a:
1 = yes
2 = no.
(11)
Exceed Budget Amount
L5B
Enter the following from the checkbox Schedule H, Part I, Line 5b:
1 = yes
2 = no.
(12)
Unable to Provide Free or Discounted Care
L5C
Enter the following from the checkbox Schedule H, Part I, Line 5c:
1 = yes
2 = no.
(13)
Prepare A Community Benefit Report
L6A
Enter the following from the checkbox Schedule H, Part I, Line 6a:
1 = yes
2 = no.
(14)
Available to Public
L6B
Enter the following from the checkbox Schedule H, Part I, Line 6b:
1 = yes
2 = no.
(15)
Financial Assistance C
L7AC $
Enter the amount from Schedule H, Part I, Line 7a, Column (c).
(16)
Financial D
L7AD $
Enter the amount from Schedule H, Part I, Line 7a, Column (d).
(17)
Financial Assistance at Cost Net Community
SCHH 7A(E) $
Enter the amount from Schedule H, Part I, Line 7a, Column (e).
(18)
Financial Assistance at Cost Percent
7A(F)
Enter the percent from Schedule H, Part I, Line 7a, Column (f).
(19)
Medicaid C
L7BC $
Enter the amount from Schedule H, Part I, Line 7b, Column (c).
(20)
Medicaid D
L7BD $
Enter the amount from Schedule H, Part I, Line 7b, Column (d).
(21)
Unreimbursed Medicaid Net Community
7B(E) $
Enter the amount from Schedule H, Part I, Line 7b, Column (e).
(22)
Unreimbursed Medicaid Percent
7B(F)
Enter the percent from Schedule H, Part I, Line 7b, Column (f).
(23)
Cost of Other Means Tested C
L7CC $
Enter the amount from Schedule H, Part I, Line 7c, Column (c).
(24)
Cost of Other Means Tested D
L7DC $
Enter the amount from Schedule H, Part I, Line 7c, Column (d).
(25)
Unreimbursed Costs - Other Net Community
7C(E) $
Enter the amount from Schedule H, Part I, Line 7c, Column (e).
(26)
Unreimbursed Costs - Other Percent
7C(F)
Enter the percent from Schedule H, Part I, Line 7c, Column (f).
(27)
Financial Assistance Total C
7DC $
Enter the amount from Schedule H, Part I, Line 7d, Column (c).
(28)
Financial Assistance Total D
7DD $
Enter the amount from Schedule H, Part I, Line 7d, Column (d).
(29)
Total Financial Assistance Net Community
7D(E) $
Enter the amount from Schedule H, Part I, Line 7d, Column (e).
(30)
Total Financial Assistance Percent
7D(F)
Enter the percent from Schedule H, Part I, Line 7d, Column (f).
Form 990 - Section 32, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Community Health Improvement C
7EC $
Enter the amount from Schedule H, Part I, Line 7e, Column (c).
(3)
Community Health Improvement D
7ED $
Enter the amount from Schedule H, Part I, Line 7e, Column (d).
(4)
Community Health Improvement E
7EE $
Enter the amount from Schedule H, Part I, Line 7e, Column (e).
(5)
Community Health Improvement Percent
7EF%
Enter the percent from Schedule H, Part I, Line 7e, Column (f).
(6)
Health Professions C
7FC $
Enter the amount from Schedule H, Part I, Line 7f, Column (c).
(7)
Health Professions D
7ED $
Enter the amount from Schedule H, Part I, Line 7f, Column (d).
(8)
Health Professions E
7FE $
Enter the amount from Schedule H, Part I, Line 7f, Column (e).
(9)
Health Professions Percent
7FF%
Enter the percent from Schedule H, Part I, Line 7f, Column (f).
(10)
Subsidized Health Services C
7GC $
Enter the amount from Schedule H, Part I, Line 7g, Column (c).
(11)
Subsidized Health Services D
7GD $
Enter the amount from Schedule H, Part I, Line 7g, Column (d).
(12)
Subsidized Health Services E
7GE $
Enter the amount from Schedule H, Part I, Line 7g, Column (e).
(13)
Subsidized Health Services Percent
7GF%
Enter the percent from Schedule H, Part I, Line 7g, Column (f).
(14)
Research C
7HC $
Enter the amount from Schedule H, Part I, Line 7h, Column (c).
(15)
Research D
7HD $
Enter the amount from Schedule H, Part I, Line 7h, Column (d).
(16)
Research E
7HE $
Enter the amount from Schedule H, Part I, Line 7h, Column (e).
(17)
Research F Percent
7HF%
Enter the percent from Schedule H, Part I, Line 7h, Column (f).
(18)
Cash & Contributions C
7IC $
Enter the amount from Schedule H, Part I, Line 7i, Column (c).
(19)
Cash & Contributions D
7ID $
Enter the amount from Schedule H, Part I, Line 7i, Column (d).
(20)
Cash & Contributions E
7IE $
Enter the amount from Schedule H, Part I, Line 7i, Column (e).
(21)
Cash & Contributions %
7IF%
Enter the percent from Schedule H, Part I, Line 7i, Column (f).
(22)
Total Other Benefits C
7JC $
Enter the amount from Schedule H, Part I, Line 7j, Column (c).
(23)
Total Other Benefits D
7JD $
Enter the amount from Schedule H, Part I, Line 7j, Column (d).
(24)
Total Other Benefits E
7JE $
Enter the amount from Schedule H, Part I, Line 7j, Column (e).
(25)
Total Other Benefits Percent
7JF%
Enter the percent from Schedule H, Part I, Line 7j, Column (f).
(26)
Total C
7KC $
Enter the amount from Schedule H, Part I, Line 7k, Column (c).
(27)
Total D
7KD $
Enter the amount from Schedule H, Part I, Line 7k, Column (d).
(28)
Total E
7KE $
Enter the amount from Schedule H, Part I, Line 7k, Column (e).
(29)
Total Percent
7KF%
Enter the percent from Schedule H, Part I, Line 7k, Column (f).
Form 990 - Section 33, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Net Community
PIII0E $
Enter the amount from Schedule H, Part II, Line 10, Column (e).
(3)
Total Percent of Expense
10F%
Enter the percent from Schedule H, Part II, Line 10 Column (f).
(4)
Report Bad Debt Expense
PT3L1
Enter a yes or no from the yes/no box on Sch H, Part III, Line 1.
(5)
Bad Debt Expense Amount
L2 $
Enter the amount from Schedule H, Part III, Line 2.
(6)
Estimated Bad Debt Expense Amount
L3 $
Enter the amount from Schedule H, Part III, Line 3.
(7)
Revenue from Medicare
L5 $
Enter the amount from Schedule H, Part III, Line 5.
(8)
Medicare Allowable Costs
L6 $
Enter the amount from Schedule H, Part III, Line 6.
(9)
Medicare Surplus or Shortfall
L7 $
Enter the amount from Schedule H, Part III, Line 7.
(10)
Costing Methodology or Source Code
L8CD
Enter the edited code from the right of the boxes from Schedule H, Part III, Line 8.
(11)
Written Debt Collection Policy
L9A
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9a.
(12)
Collection Policy Contain Provision
L9B
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9b.
(13)
Part IV Code
PIVCD
Enter the edited digit from Schedule H, Part IV, right margin.
(14)
Part V How Many Hospital Facilities Did Organization Operate
SECATOP
Enter the number shown in the Hospital Facilities area in the top left portion of Schedule H, Part V, Section A.
(15)
Part V Section C Indicator Code
SECCRM
Enter the indicator code from Schedule H, Part V, Section C, right margin.
(16)
Part V How Many Non-Hospital Facilities Did Organization Operate
SECCTOP
Enter the number from the non-hospital health care benefits line.
(17)
Part V Section D Indicator Code
SECTDRM
Enter the edited code from Schedule H, Part V, Section D, right margin.
Form 990 - Section 34, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 35, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 36, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19d is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 37, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 38, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 39, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 40, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 41, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 42, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 43, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 44, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 45, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 46, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility Section B
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Licensed Registered State Y/N
PVL1
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 1.
(5)
Hospital Acquired in Current Year Y/N
P2VL
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 2.
(6)
Conduct Community Health Needs Assessment
L3
Enter a yes or no from the yes/no box on Sch H, Part V, Section B Line 3.
(7)
Definition of Community Served
L3A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3a is checked.
(8)
Demographics of a Community
L3B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3b is checked.
(9)
Existing Health Care and Resources
L3C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3c is checked.
(10)
How Data Was Obtained
L3D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3d is checked.
(11)
Health Needs of a Community
L3E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3e is checked.
(12)
Primary and Chronic Disease Needs
L3F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3f is checked.
(13)
Identifying and Prioritizing Health Needs
L3G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3g is checked.
(14)
Consulting With Persons Representing
L3H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3h is checked.
(15)
Information Gaps That Limit
L3I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3i is checked.
(16)
Other
L3J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 3j is checked.
(17)
Tax Year CHNA Conducted
L4
Enter the two-digit year field from Schedule H, Part V, Section B, Line 4.
(18)
Hospital Facility Take Into Account Input
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(19)
Conducted With One or More Other Hospitals Facilities
L6A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6a.
(20)
CHNA Conducted With One or More Organizations Other Than Hospital Facilities
L6B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 6b.
(21)
Widely Available to Public
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(22)
Hospital Website
L7A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7a is checked.
(23)
Other Website
L7B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7b is checked.
(24)
Paper Copy Available Without Charge
L7C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7c is checked.
(25)
Other
L7D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 7d is checked.
(26)
Adopt Implementation Strategy
L8
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8.
(27)
Tax Year Strategy Implemented
L9
Enter the year from Schedule H, Part V, Section B, Line 9.
(28)
Strategy Posted on Website
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(29)
URL Present
L10A
Enter a 1 if a url is present on Schedule H, Part V, Section B, Line 10a.
(30)
Strategy Attached
L10B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10b.
(31)
Excise Tax Under 4959
L12A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12a.
(32)
Did Organization File 4720
L12B
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 12b.
(33)
4959 Tax Reported
L12C $
Enter the amount on Schedule H, Part V, Section B, Line 12c.
(34)
Explained Eligibility Requirement
L13
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(35)
Uses Federal Poverty Guidelines Free Care
L13A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13a is checked.
(36)
Free Care %
13A1%
Enter the first percent on Schedule H, Part V, Section B, Line 13a.
(37)
Discounted Care %
13A2%
Enter the second percent on Schedule H, Part V, Section B, Line 13a.
(38)
Income Level Other Than FPG
L13B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13b is checked.
(39)
Asset Level
L13C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13c is checked.
(40)
Medical Indigency
13D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13d is checked.
(41)
Insurance Status
13E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13e is checked.
(42)
Underinsurance Status
13F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13f is checked.
(43)
Residency
13G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13g is checked.
(44)
Other
13H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 13h is checked.
Form 990 - Section 47, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Calculating Amounts Charged to Patients
14
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(3)
Explained the Method for Applying Financial Assistance
15
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(4)
Information Hospital Required on Application
15A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15a is checked.
(5)
Supporting Information Required on Application
15B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15b is checked.
(6)
Contact Information
15C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15c is checked.
(7)
Contact Information Sources of Financial Assistance
15D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15d is checked.
(8)
Other
15E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 15e is checked.
(9)
Publicize the Policy
16
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 16.
(10)
FAP Available on Website
16A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16a is checked.
(11)
FAP Application on Website
16B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16b is checked.
(12)
Plain Language Summary
16C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16c is checked.
(13)
FAP Available on Request
16D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16d is checked.
(14)
FAP Application Form Available Upon Request
16E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16e is checked.
(15)
Plain Language FAP Available
16F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16f is checked.
(16)
FAP Conspicuously Displayed
16G
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16g is checked.
(17)
Notified Customers
16H
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16h is checked.
(18)
FAP Translated into Primary Language of LEP
16I
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16i is checked.
(19)
Other
16J
Enter a 1 if the box on Schedule H, Part V, Section B, Line 16j is checked.
(20)
Separate Billing and Collections Billing
17
Enter a a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(21)
Reporting to Credit Agency
18A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18a is checked.
(22)
Selling an Individuals Debt
18B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18b is checked.
(23)
Deferring, Denying or Requesting a Payment
18C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18c is checked.
(24)
Actions That Require Legal or Judicial Process
18D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18d is checked.
(25)
Other Similar Actions
18E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18e is checked.
(26)
None of These Actions
18F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 18f is checked.
Form 990 - Section 48, Schedule H (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Individuals Availability Under Facilities FAP
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(3)
Reporting to Credit Agency
19A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19a is checked.
(4)
Selling an Individuals Debt
19B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19b is checked.
(5)
Deferring, Denying or Requesting a Payment
19C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19c is checked.
(6)
Actions That Require Legal or Judicial Process
19D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19dc is checked.
(7)
Other Similar Actions
19E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 19e is checked.
(8)
Provided a Written Notice
20A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20a is checked.
(9)
Reasonable Effort to Orally Notify
20B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20b is checked.
(10)
Processed Complete and Incomplete FAP
20C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20c is checked.
(11)
Made Presumptive Eligibility Determinations
20D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20d is checked.
(12)
Other
20E
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20e is checked.
(13)
None of These Efforts
20F
Enter a 1 if the box on Schedule H, Part V, Section B, Line 20f is checked.
(14)
Written Policy to Emergency Medical Dare Policy
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(15)
Did Not Provide Care for Emergency Medical Conditions
21A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21a is checked.
(16)
Did Not Have Policy Relating to Emergency Medical Care
21B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21b is checked.
(17)
Limited Who Was Eligible
21C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21c is checked.
(18)
Other
21D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 21d is checked.
(19)
Look Back Method Allowed by a Medicare Fee
22A
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22a is checked.
(20)
Look Back Method Allowed by a Medicare Fee and Private Insurance
22B
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22b is checked.
(21)
Look Back Method Allowed by Medicaid Either Alone or Combination of Medicare
22C
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22c is checked.
(22)
Prospective Medicaid or Medicare Method
22D
Enter a 1 if the box on Schedule H, Part V, Section B, Line 22d is checked.
(23)
Charge Any of Its Patients
23
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 23.
(24)
Amount Equal to the Gross Charge
24
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 24.
Form 990 - Section 49 Schedules L and R (2019 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Excess Benefit Transactions
PT1 RTMAR
Enter the edited digit from the right margin of Schedule L, Part 1.
(3)
Approved by Board or Committee
PT2 RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
(4)
Interest, Annuities, Royalties, Yes/No Box
SCHR PT51A
Enter a yes or a no from the yes/no box from Schedule R, Part V, Line 1a.
Form 990 - Section 01 (2008 - 2013) CP 425–431 & 259A-259H¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generates the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present. (a) If not present, press
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block. (a) For a CP 425–431 & 259A-259H, underlined to the right of the "Employer ID Number" . (b) See standard rules in IRM 3.24.38. (c) For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
For a CP 425–431 & 259A-259H, edited in the area around the Tax Period.
(10)
In Care of Name Line
C/O NAME
Enter the in-care-of name, if shown.
Note:¶
Downstream processing generates the (%) sign.
(11)
Foreign Address
FGN ADD
Enter the foreign street address, if shown. See IRM 3.24.38 for additional instructions.
(12)
Street Address
ADDR
Enter the street address from the address line.
See IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information, even if prompted to do so. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(13)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country code.
(14)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.)
(15)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
(16)
Group Code H(b)
BOXHB
Enter a "1" or "2" from the yes/no box from the entity area of the return, Line H(b). For a CP425–431 & 259A-259H, press
(17)
Tax Exempt Status
BOXI
Enter the edited two digit code from the blank space of Box I.
(18)
Type of Organization
BOXK RT
Enter the edited code from the blank space of Box K. For a CP 425–431 & 259A-259H enter a "9" .
(19)
Computer Condition Codes
CCC
Enter the edited characters as shown on dotted portion of Lines 2–7b. For a 420–431 & 259A-259H, enter the edited characters as shown in the center of the return. If a Condition Code is illegible, enter a "#" in its place.
(20)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM 3.24.38 for special instructions.
If a "G" Condition Code is present and the return is non-remittance, end the document after this element.
If a CP 425–431 & 259A-259H, end the document after this element.
(21)
Preparation Code
PREP
Enter the edited code from the right of the preparer PTIN Line.
(22)
Preparer PTIN
PTIN
Enter the Preparer's PTIN.
(23)
Preparer's EIN
PEIN
Enter the preparer's EIN.
(24)
Preparer Telephone #
TEL#
Enter the preparer phone number.
If the Type of Organization is a "9" , and the "9" is underlined, don't end the document. Continue transcribing the return.
If Type of Organization is a "9" , and the "9" is NOT underlined, press
(25)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and the return is a remittance, Press
If the Type of Organization is "9" from Section 01 E–10 and the " 9" is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is "9" , and the "9" is NOT underlined, press
Form 990 - Section 02, Form 5800 - Edit Sheet (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(3)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(4)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(5)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800, in MMDDYY format. (a) For special instructions, see IRM 3.24.38.
(6)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990 - Section 03 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return, ONLY if underlined in green.
(3)
IRI Codes
PG2TOP
Enter the edited digits from the top of page 2.
(4)
Undertake New Activities Y/N
L2
Enter a yes or no from the yes/no box from Part III, Line 2.
(5)
Make Significant Changes Y/N
L3
Enter a yes or no from the yes/no box from Part III, Line 3.
(6)
Exempt Purpose Code 1
L4A
Press Enter only. Don't transcribe a code.
(7)
Exempt Purpose Code 2
L4B
Press Enter only. Don't transcribe a code.
(8)
Exempt Purpose Code 3
L4C
Press Enter only. Don't transcribe a code.
(9)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
Note:¶
If a "D1" is edited and underlined, pick up as an alpha "D" and numeric "1" . Don't confuse with an alpha "D" and alpha "I" .
(10)
501(c)(3) or 4947(a)(1) Y/N
L1
Enter a yes or no from the yes/no box from Part IV, Line 1.
(11)
Required to Complete Sch B Y/N
L2
Enter a yes or no from the yes/no box from Part IV, Line 2.
(12)
Engage in Direct or Indirect Political Y/N
L3
Enter a yes or no from the yes/no box from Part IV, Line 3.
(13)
Engage in Lobbying Activities Y/N
L4
Enter a yes or no from the yes/no box from Part IV, Line 4.
(14)
Subject to Sec 6033(c) Notice
L5
Enter a yes or no from the yes/no box from Part IV, Line 5.
(15)
Maintain Donor Advised Y/N
L6
Enter a yes or no from the yes/no box from Part IV, Line 6.
(16)
Receive or Hold Conservation Y/N
L7
Enter a yes or no from the yes/no box from Part IV, Line 7.
(17)
Maintain Collections of Works of Art Y/N
L8
Enter a yes or no from the yes/no box from Part IV, Line 8.
(18)
Provide Credit Counseling Y/N
L9
Enter a yes or no from the yes/no box from Part IV, Line 9.
(19)
Hold Assets in Term/Permanent Y/N
L10
Enter a yes or no from the yes/no box from Part IV, Line 10.
(20)
Land, Buildings, Equipment
11A
Enter a yes or no from the yes/no box from Part IV, Line 11a.
(21)
Investments Other Securities
11B
Enter a yes or no from the yes/no box from Part IV, Line 11b.
(22)
Investments Program Related
11C
Enter a yes or no from the yes/no box from Part IV, Line 11c.
(23)
Other Assets
11D
Enter a yes or no from the yes/no box from Part IV, Line 11d.
(24)
Other Liabilities
11E
Enter a yes or no from the yes/no box from Part IV, Line 11e.
(25)
Separate or Consolidated Financial Statements
11F
Enter a yes or no from the yes/no box from Part IV, Line 11f.
(26)
Separate Independent Audited Financial
12A
Enter a yes or no from the yes/no box from Part IV, Line 12a.
(27)
Consolidated Independent Financial
12B
Enter a yes or no from the yes/no box from Part IV, Line 12b.
(28)
School Described in 170(b)(1)(A)(ii)
L13
Enter a yes or no from the yes/no box from Part IV, Line 13.
(29)
Maintain an Office, etc Outside U.S.
14A
Enter a yes or no from the yes/no box from Part IV, Line 14a.
(30)
Have Aggregate Revenues/Expenses
14B
Enter a yes or no from the yes/no box from Part IV, Line 14b.
(31)
Report > $5000 on Part IX Organizations
L15
Enter a yes or no from the yes/no box from Part IV, Line 15.
(32)
Report > $5000 on Part IX Individuals
L16
Enter a yes or no from the yes/no box from Part IV, Line 16.
(33)
Report > $15,000 on Part IX, Line 11e
L17
Enter a yes or no from the yes/no box from Part IV, Line 17.
(34)
Report > $15,000 on Part VIII, Line 1c/8a
L18
Enter a yes or no from the yes/no box from Part IV, Line 18.
(35)
Report > $15,000 on Part VIII, Line 9a
L19
Enter a yes or no from the yes/no box from Part IV, Line 19.
(36)
Operate Hospitals
20A
Enter a yes or no from the yes/no box from Part IV, Line 20a.
(37)
Attach Audited Financial Statements
20B
Enter a yes or no from the yes/no box from Part IV, Line 20b.
Form 990 - Section 04 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Report > $5000 on Part IX, Line 1
L21
Enter a yes or no from the yes/no box from Part IV, Line 21.
(3)
Report > $5000 on Part IX, Line 2
L22
Enter a yes or no from the yes/no box from Part IV, Line 22.
(4)
Answer Yes to Questions 3, 4, 5
L23
Enter a yes or no from the yes/no box from Part IV, Line 23.
(5)
Any Tax-Exempt Bond with Outstanding Principal
24A
Enter a yes or no from the yes/no box from Part IV, Line 24a.
(6)
Invest Any Proceeds
24B
Enter a yes or no from the yes/no box from Part IV, Line 24b.
(7)
Maintain an Escrow Account
24C
Enter a yes or no from the yes/box from Part IV, Line 24c.
(8)
Act as "On Behalf Of" Issuer
24D
Enter a yes or no from the yes/no box from Part IV, Line 24d.
(9)
501(c)(3) / 501(c)(4) Organizations
25A
Enter a yes or no from the yes/no box from Part IV, Line 25a.
(10)
Become Aware it Engaged in Excess
25B
Enter a yes or no from the yes/no box from Part IV, Line 25b.
(11)
Loan to/by Current/Former Officer
L26
Enter a yes or no from the yes/no box from Part IV, Line 26.
(12)
Provide Grant or Other Assistance
L27
Enter a yes or no from the yes/no box from Part IV, Line 27.
(13)
Business Transaction with Current or Former Officer
28A
Enter a yes or no from the yes/no box from Part IV, Line 28a.
(14)
Business Transaction with Family Member
28B
Enter a yes or no from the yes/no box from Part IV, Line 28b.
(15)
Business Transaction with Entity of Current/Former Officer
28C
Enter a yes or no from the yes/no box from Part IV, Line 28c.
(16)
Receive or Accrue > $25,000 in Non-Cash
L29
Enter a yes or no from the yes/no box from Part IV, Line 29.
(17)
Receive or Accrue Contributions of Art
L30
Enter a yes or no from the yes/no box from Part IV, Line 30.
(18)
Liquidate, Terminate, Dissolve
L31
Enter a yes or no from the yes/no box from Part IV, Line 31.
(19)
Sell, Exchange, Dispose
L32
Enter a yes or no from the yes/no box from Part IV, Line 32.
(20)
Own 100% of an Entity
L33
Enter a yes or no from the yes/no box from Part IV, Line 33.
(21)
Related to Tax-Exempt / Taxable Entity
L34
Enter a yes or no from the yes/no box from Part IV, Line 34.
(22)
Controlled Entity Within 512(b)(13)
L35A
Enter a yes or no from the yes/no box from Part IV, Line 35a.
23
Receive Payment or Engage Transaction Within
L35B
Enter a yes or no from the yes/no box from Part IV, Line 35b.
(24)
Make Any Transfers
L36
Enter a yes or no from the yes/no box from Part IV, Line 36.
(25)
Conduct More than 5%
L37
Enter a yes or no from the yes/no box from Part IV, Line 37.
(26)
Complete Schedule O
L38
Enter a yes or no from the yes/no box from Part IV, Line 38.
Form 990 - Section 05 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part V Number of Forms/1096
PTVL1A
Enter the number shown on Part V, Line 1a.
(3)
Number of Forms W-2G
L1B
Enter the number shown on Part V, Line 1b.
(4)
Comply with Backup Withholding Rules
L1C
Enter a yes or no from the yes/no box from Part V, Line 1c.
(5)
Number of Employees / W-3
L2A
Enter the number shown on Part V, Line 2a.
(6)
File All Required Federal Employment Returns
L2B
Enter a yes or no from the yes/no box from Part V, Line 2b.
(7)
Unrelated Business Income > $1000
L3A
Enter a yes or no from the yes/box from Part V, Line 3a.
(8)
If Yes, Has Filed a 990-T
L3B
Enter a yes or no from the yes/no box from Part V, Line 3b.
(9)
Interest in or a Signature
L4A
Enter a yes or no from the yes/no box from Part V, Line 4a.
(10)
Party to a Prohibited Tax Shelter
L5A
Enter a yes or no from the yes/no box from Part V, Line 5a.
(11)
Taxable Party Notify Organization
L5B
Enter a yes or no from the yes/no box from Part V, Line 5b.
(12)
If Yes, Did Organization File 8886-T
L5C
Enter a yes or no from the yes/no box from Part V, Line 5c.
(13)
Annual Gross Receipts Normally >$100,000
L6A
Enter a yes or no from the yes/no box from Part V, Line 6a.
(14)
If Yes, Did Organization Include
L6B
Enter a yes or no from the yes/no box from Part V, Line 6b.
(15)
$75 Partly Contribution/Goods/Services
L7A
Enter a yes or no from the yes/no box from Part V, Line 7a.
(16)
If Yes, Did Organization Notify Donor
L7B
Enter a yes or no from the yes/no box from Part V, Line 7b.
(17)
Sell, Exchange, Otherwise Dispose
L7C
Enter a yes or no from the yes/no box from Part V, Line 7c.
(18)
Number of Forms 8282
L7D
Enter the number shown on Part V, Line 7d.
(19)
Receive Any Funds
L7E
Enter a yes or no from the yes/no box from Part V, Line 7e.
(20)
Pay Premiums
L7F
Enter a yes or no from the yes/no box from Part V, Line 7f.
(21)
Contributions of Qualified Intellectual Property
L7G
Enter a yes or no from the yes/no box from Part V, Line 7g.
(22)
Contributions of Cars, Boats, Airplanes
L7H
Enter a yes or no from the yes/no box from Part V, Line 7h.
(23)
Sponsoring Orgs, 509(a)(3) Excess Business Holdings
L8
Enter a yes or no from the yes/no box from Part V, Line 8.
(24)
Make Taxable Distributions Under 4966
L9A
Enter a yes or no from the yes/no box from Part V, Line 9a.
(25)
Make Distribution to Donor
L9B
Enter a yes or no from the yes/no box from Part V, Line 9b.
(26)
Initiation Fees/Capital Contributions
10A $
Enter the amount from Part V, Line 10a.
(27)
Gross Receipts for Public Use of Facilities
10B $
Enter the amount from Part V, Line 10b.
(28)
Gross Income/Members/Shareholders
11A $
Enter the amount from Part V, Line 11a.
(29)
Gross Income from Other Sources
11B $
Enter the amount from Part V, Line 11b.
(30)
4947(a)(1) Filing 990 in Lieu of 1041
12A
Enter a yes or no from the yes/no box from Part V, Line 12a.
(31)
Amount of Tax Exempt Interest
12B $
Enter the amount from Part V, Line 12b.
(32)
Licensed to Issue Qualified Health Plans
13A
Enter a yes or no from the yes/no box from Part V, Line 13a.
(33)
Aggregate Amount of Reserves to Maintain
13B $
Enter the amount from Part V, Line 13b.
(34)
Aggregate Amount of Reserves on Hand
13C $
Enter the amount from Part V, Line 13c.
(35)
Receive Payments for Indoor Tanning
14A
Enter a yes or no from the yes/no box from Part V, Line 14a.
(36)
Filed Form 720 to Report Payments
14B
Enter a yes or no from the yes/no box from Part V, Line 14b.
Form 990 - Section 06 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Voting Members of Governing Body
PG6L1A
Enter the number shown on Part VI, Section A, Line 1a.
(3)
Independent Voting Members
L1B
Enter the number shown on Part VI, Section A, Line 1b.
(4)
Officer, Director, Trustee Family/Relationship
L2
Enter a yes or no from the yes/no box from Part VI, Section A, Line 2.
(5)
Delegate Control Over Management
L3
Enter a yes or no from the yes/no box from Part VI, Section A, Line 3.
(6)
Make Significant Changes
L4
Enter a yes or no from the yes/no box from Part VI, Section A, Line 4.
(7)
Become Aware of Material Diversion
L5
Enter a yes or no from the yes/box from Part VI, Section A, Line 5.
(8)
Members of Stockholders
L6
Enter a yes or no from the yes/no box from Part VI, Section A, Line 6.
(9)
Members, Stockholders, Other Persons
7A
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7a.
(10)
Members Subject to Approval
7B
Enter a yes or no from the yes/no box from Part VI, Section A, Line 7b.
(11)
Determining Compensation for CEO, Exec Director
15A
Enter a yes or no from the yes/no box from Part VI, Section B, Line 15a
(12)
Total Reportable Compensation from Organization
PG8L1D(D) $
Enter the amount from Part VII, Section A, Line 1d, Column D.
(13)
Total Reportable Compensation from Related Organization
1D(E) $
Enter the amount from Part VII, Section A, Line 1d, Column E.
(14)
Total Compensation from Organization & Related Organizations
1D(F) $
Enter the amount from Part VII, Section A, Line 1d, Column F.
(15)
Total Individuals who Received > $100,000
SECTAL2
Enter the number shown on Part VII, Section A, Line 2.
(16)
Total Independent Contractors Received > $100,000
SECTBL2
Enter the number shown on Part VII, Section B, Line 2.
Form 990 - Section 07 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Contributions/Gifts/Grants
PG9L1H $
Enter the amount from Part VIII, Line 1h, Column (A).
(3)
Program Service Business Code 2A
2ACODE
Enter the number shown on Part VIII, Line 2a.
(4)
2a Program Service Revenue Col. A
2A(A) $
Enter the amount from Part VIII, Line 2a, Column (A).
(5)
Program Service Business Code 2B
2BCODE
Enter the number shown on Part VIII, Line 2b.
(6)
2b Program Service Revenue Col. A
2B(A) $
Enter the amount from Part VIII, Line 2b, Column (A).
(7)
Program Service Business Code 2C
2CCODE
Enter the number shown on Part VIII, Line 2c.
(8)
2c Program Service Revenue Col. A
2C(A) $
Enter amount shown on Part VIII, Line 2c, Column (A).
(9)
Program Service Business Code 2D
2DCODE
Enter the number shown on Part VIII, Line 2d.
(10)
2d Program Service Revenue Col. A
2D(A) $
Enter amount shown on Part VIII, Line 2d, Column (A).
(11)
Program Service Business Code 2E
2ECODE
Enter the number shown on Part VIII, Line 2e.
(12)
2e Program Service Revenue Col. A
2E(A) $
Enter the amount from Part VIII, Line 2e, Column (A).
(13)
2f Program Service Revenue Col. A
2F(A) $
Enter the amount from Part VIII, Line 2f, Column (A).
(14)
2g Program Service Revenue Total Col. A
2GTOT $
Enter the amount from Part VIII, Line 2g, Column (A).
(15)
Investment Income Col. A
3(A) $
Enter the amount from Part VIII, Line 3, Column (A).
(16)
Tax-Exempt Bond Proceeds Col. A
4(A) $
Enter the amount from Part VIII, Line 4, Column (A).
(17)
Royalties Col. A
5(A) $
Enter the amount from Part VIII, Line 5, Column (A).
(18)
Gross Rents Real
6(A)I $
Enter the amount from Part VIII, Line 6a, Column (i).
(19)
Gross Rents Personal
6(A)II $
Enter the amount from Part VIII, Line 6a, Column (ii).
(20)
Rental Expenses Real
6(B)(I) $
Enter the amount from Part VIII, Line 6b, Column (i).
(21)
Rental Expenses Personal
6(B)(II) $
Enter the amount from Part VIII, Line 6b, Column (ii).
(22)
Rental Income/Loss Real
6C(I) $
Enter the amount from Part VIII, Line 6c, Column (i).
(23)
Rental Income/Loss Personal
6C(II) $
Enter the amount from Part VIII, Line 6c, Column (ii).
(24)
Net Rental Income/Loss Col. A
6D(A) $
Enter the amount from Part VIII, Line 6d, Column (A).
Form 990 - Section 08 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross Amount from Sales of Assets - Securities
PG9L7A(I) $
Enter the amount from Part VIII, Line 7a, Column (i).
(3)
Gross Amount from Sales of Assets - Other
7A(II) $
Enter the amount from Part VIII, Line 7a, Column (ii).
(4)
Cost or Other Basis/Sales - Securities
7B(I) $
Enter the amount from Part VIII, Line 7b, Column (i).
(5)
Cost or Other Basis/Sales - Other
7B(II) $
Enter the amount from Part VIII, Line 7b, Column (ii).
(6)
Gain/Loss - Securities
7C(I) $
Enter the amount from Part VIII, Line 7c, Column (i).
(7)
Gain/Loss - Other
7C(II) $
Enter the amount from Part VIII, Line 7c, Column (ii).
(8)
Net Gain/Loss Col. A
7D(A) $
Enter the amount from Part VIII, Line 7d, Column (A).
(9)
Gross Income from Fundraising
8A $
Enter the amount from Part VIII, Line 8a.
(10)
Less Direct Expenses 8b
8B $
Enter the amount from Part VIII, Line 8b.
(11)
Net Income/Loss from Fundraising Col. A
8C(A) $
Enter the amount from Part VIII, Line 8c, Column (A).
(12)
Gross Income from Gaming
9A $
Enter the amount from Part VIII, Line 9a.
(13)
Less Direct Expenses 9b
9B $
Enter the amount from Part VIII, Line 9b.
(14)
Net Income/Loss from Gaming
9C(A) $
Enter the amount from Part VIII, Line 9c, Column (A).
(15)
Gross Sales of Inventory
10A $
Enter the amount from Part VIII, Line 10a.
(16)
Less Cost of Goods Sold
10B $
Enter the amount from Part VIII, Line 10b.
(17)
Net Income/Loss from Sales Col. A
10C(A) $
Enter the amount from Part VIII, Line 10c, Column (A).
(18)
Misc. Revenue Business Code 11a
11ACODE
Enter the number shown on Part VIII, Line 11a.
(19)
Misc. Revenue Total (A) Col. A
11A(A) $
Enter the amount from Part VIII, Line 11a, Column (A).
(20)
Misc. Revenue Business Code 11b
11BCODE
Enter the number shown on Part VIII, Line 11b.
(21)
Misc. Revenue Total 11B(A) Col. A
11B(A) $
Enter the amount from Part VIII, Line 11b, Column (A).
(22)
Misc. Revenue Business Code 11c
11CCODE
Enter the number shown on Part VIII, Line 11c.
(23)
Misc. Revenue Total 11C(A) Col. A
11C(A) $
Enter the amount from Part VIII, Line 11c, Column (A).
(24)
Misc. Revenue Total 11D(A) Col. A
11D(A) $
Enter the amount from Part VIII, Line 11d, Column (A).
(25)
Misc. Revenue Total 11E Col. A
11ETOT $
Enter the amount from Part VIII, Line 11e, Column (A).
(26)
Total Revenue 12(A) Col. A
12(A) $
Enter the amount from Part VIII, Line 12, Column (A).
Form 990 - Section 09 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Gross to Government / Organizations in U.S.
PG10L1(A) $
Enter the amount from Part IX, Line 1, Column (A).
(3)
Grants / Other Assistance in U.S.
L2(A) $
Enter the amount from Part IX, Line 2, Column (A).
(4)
Grants / Other Assistance Outside U.S.
L3(A) $
Enter the amount from Part IX, Line 3, Column (A).
(5)
Benefits Paid to / for Members
L4(A) $
Enter the amount from Part IX, Line 4, Column (A).
(6)
Compensation of Current Officers / Directors
L5(A) $
Enter the amount from Part IX, Line 5, Column (A).
(7)
Compensation to Disqualified Persons
L6(A) $
Enter the amount from Part IX, Line 6, Column (A).
(8)
Other Salaries / Wages
L7(A) $
Enter the amount from Part IX, Line 7, Column (A).
(9)
Pension Plan Contributions
L8(A) $
Enter the amount from Part IX, Line 8, Column (A).
(10)
Other Employee Benefits
L9(A) $
Enter the amount from Part IX, Line 9, Column (A).
(11)
Payroll Taxes
10(A) $
Enter the amount from Part IX, Line 10, Column (A).
(12)
Fees for Services / Management
11A(A) $
Enter the amount from Part IX, Line 11a, Column (A).
(13)
Fees for Services / Legal
11B(A) $
Enter the amount from Part IX, Line 11b, Column (A).
(14)
Fees for Services / Accounting
11C(A) $
Enter the amount from Part IX, Line 11c, Column (A).
(15)
Fees for Services / Lobbyists
11D(A) $
Enter the amount from Part IX, Line 11d, Column (A).
(16)
Fees for Services / Professional Fundraising
11E(A) $
Enter the amount from Part IX, Line 11e, Column(A).
(17)
Fees for Services / Investment Management
11F(A) $
Enter the amount from Part IX, Line 11f, Column (A).
(18)
Fees for Services / Other
11G(A) $
Enter the amount from shown on Part IX, Line 11g, Column (A).
(19)
Advertising / Promotion
12(A) $
Enter the amount from Part IX, Line 12, Column (A).
(20)
Office Expenses
13(A) $
Enter the amount from on Part IX, Line 13, Column (A).
(21)
Information Technology
14(A) $
Enter the amount from Part IX, Line 14, Column (A).
(22)
Royalties
15(A) $
Enter the amount from Part IX, Line 15, Column (A).
(23)
Occupancy
16(A) $
Enter the amount from Part IX, Line 16, Column (A).
(24)
Travel
17(A) $
Enter the amount from Part IX, Line 17, Column (A).
(25)
Payments of Travel / Entertainment
18(A) $
Enter the amount from Part IX, Line 18, Column (A).
(26)
Conferences, Conventions / Meetings
19(A) $
Enter the amount from Part IX, Line 19, Column (A).
(27)
Interest
20(A) $
Enter the amount from Part IX, Line 20, Column (A).
(28)
Payments to Affiliates
21(A) $
Enter the amount from Part IX, Line 21, Column (A).
(29)
Depreciation / Depletion
22(A) $
Enter the amount from Part IX, Line 22, Column (A).
(30)
Insurance
23(A) $
Enter the amount from Part IX, Line 23, Column (A).
(31)
Other Expenses a
24A(A) $
Enter the amount from Part IX, Line 24a, Column (A).
(32)
Other Expenses b
24B(A) $
Enter the amount from Part IX, Line 24b, Column (A).
(33)
Other Expenses c
24C(A) $
Enter the amount from Part IX, Line 24c, Column (A).
(34)
Other Expenses d
24D(A) $
Enter the amount from Part IX, Line 24d, Column (A).
(35)
Other Expenses e
24E(A) $
Enter the amount from Part IX, Line 24e, Column (A).
(36)
Other Expenses f
24F(A) $
Enter the amount from Part IX, Line 24f, Column (A).
(37)
Total Functional Expenses
25(A) $
Enter the amount from Part IX, Line 25, Column (A).
Form 990 - Section 10 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash EOY
PG11L1(B) $
Enter the amount from Part X, Line 1, Column (B).
(3)
Savings / Temporary Investments EOY
L2(B) $
Enter the amount from Part X, Line 2, Column (B).
(4)
Pledges / Grants Receivable EOY
L3(B) $
Enter the amount from Part X, Line 3, Column (B).
(5)
Accounts Receivable EOY
L4(B) $
Enter the amount from Part X, Line 4, Column (B).
(6)
Receivables from Current / Former EOY
L5(B) $
Enter the amount from Part X, Line 5, Column (B).
(7)
Receivables from Disqualified Persons EOY
L6(B) $
Enter the amount from Part X, Line 6, Column (B).
(8)
Notes / Loans Receivable EOY
L7(B) $
Enter the amount from Part X, Line 7, Column (B).
(9)
Inventories for Sale EOY
L8(B) $
Enter the amount from Part X, Line 8, Column (B).
(10)
Prepaid Expenses EOY
L9(B) $
Enter the amount from Part X, Line 9, Column (B).
(11)
Land / Buildings Less Accumulated EOY
10C(B) $
Enter the amount from Part X, Line 10c, Column (B).
(12)
Investments Publicly Traded Securities EOY
11(B) $
Enter the amount from Part X, Line 11, Column (B).
(13)
Investments Other Securities EOY
12(B) $
Enter the amount from Part X, Line 12, Column (B).
(14)
Investments Program Related EOY
13(B) $
Enter the amount from Part X, Line 13, Column (B).
(15)
Intangible Assets EOY
14(B) $
Enter the amount from Part X, Line 14, Column (B).
(16)
Other Assets EOY
15(B) $
Enter the amount from Part X, Line 15, Column(B).
(17)
Total Assets BOY
16(A) $
Enter the amount from Part X, Line 16, Column (A).
(18)
Total Assets EOY
16(B) $
Enter the amount from shown on Part X, Line 16, Column (B).
(19)
Accounts Payable EOY
17(B) $
Enter the amount from Part X, Line 17, Column (B).
(20)
Grants Payable EOY
18(B) $
Enter the amount from on Part X, Line 18, Column (B).
(21)
Deferred Revenue EOY
19(B) $
Enter the amount from Part X, Line 19, Column (B).
(22)
Tax-Exempt Bond Liabilities EOY
20(B) $
Enter the amount from Part X, Line 20, Column (B).
(23)
Escrow Liability EOY
21(B) $
Enter the amount from Part X, Line 21, Column (B).
(24)
Payable to Current / Former Officers EOY
22(B) $
Enter the amount from Part X, Line 22, Column (B).
(25)
Secured Mortgages / Notes EOY
23(B) $
Enter the amount from Part X, Line 23, Column (B).
(26)
Unsecured Notes / Loans EOY
24(B) $
Enter the amount from Part X, Line 24, Column (B).
(27)
Other Liabilities EOY
25(B) $
Enter the amount from Part X, Line 25, Column (B).
(28)
Total Liabilities BOY
26(A) $
Enter the amount from Part X, Line 26, Column (A).
(29)
Total Liabilities EOY
26(B) $
Enter the amount from Part X, Line 26, Column (B).
(30)
Unrestricted Net Assets EOY
27(B) $
Enter the amount from Part X, Line 27, Column (B).
(31)
Temporarily Restricted Net Assets EOY
28(B) $
Enter the amount from Part X, Line 28, Column (B).
(32)
Permanently Restricted Net Assets EOY
29(B) $
Enter the amount from Part X, Line 29, Column (B).
(33)
Capital Stock / Trust EOY
30(B) $
Enter the amount from Part X, Line 30, Column (B).
(34)
Paid-In / Capital Surplus EOY
31(B) $
Enter the amount from Part X, Line 31, Column (B).
(35)
Retained Earnings, Endowment EOY
32(B) $
Enter the amount from Part X, Line 32, Column (B).
(36)
Total Net Assets or Fund Balances BOY
33(A) $
Enter the amount from Part X, Line 33, Column (A).
(37)
Total Net Assets or Fund Balances EOY
33(B) $
Enter the amount from Part X, Line 33, Column (B).
(38)
Total Liabilities / Net Assets Fund Balances EOY
34(B) $
Enter the amount from Part X, Line 34, Column (B).
Form 990 - Section 11, Schedule A (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Total Number of Organizations
11H(I)TOT
Enter the number from Schedule A, Part I, Line 11h, Column (i), Total Line.
(4)
Total Amount of Support
HVIITOT $
Enter the amount from Schedule A, Part I, Line 11h, Column (vii), Total Line.
(5)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(6)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(7)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(8)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(9)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(10)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(11)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(12)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(13)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(14)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(15)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(16)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(17)
First 5 Years Checkbox
13CKBX
Enter a "1" if the box on Schedule A, Part II, Line 13 is checked.
(18)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 16a is checked.
(19)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 16b is checked.
(20)
10% Facts & Circumstances Current
17ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 17a is checked.
(21)
10% Facts & Circumstances Prior
17BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 17b is checked.
(22)
Private Foundation Checkbox
18CKBX
Enter a "1" if the box on Schedule A, Part II, Line 18 is checked.
Form 990 - Section 12, Schedule A (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter a "1" if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter a "1" if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter a "1" if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter a "1" if the box on Schedule A, Part III, Line 20 is checked.
Form 990 - Section 13, Schedules C & D (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHIAL2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Total Number at EOY
SCHDL1(A)
Enter the number shown on Schedule D, Part I, Line 1, Column (a).
(4)
Contributions To
L2(A)$
Enter the amount from Schedule D, Part I, Line 2, Column (a).
(5)
Grants From
L3(A) $
Enter the amount from Schedule D, Part I, Line 3, Column (a).
(6)
Aggregate Value
L4(A) $
Enter the amount from Schedule D, Part I, Line 4, Column (a).
(7)
Inform All Donors Checkbox
L5
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 5.
(8)
Inform All Grantees Checkbox
L6
Enter a yes or no from the yes/no box from Schedule D, Part I, Line 6.
Form 990 - Section 14, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Financial Assistance at Cost Net Community
SCHH 7A(E) $
Enter the amount from Schedule H, Part I, Line 7a, Column (e).
(3)
Financial Assistance at Cost Percent
7A(F)
Enter the percent from Schedule H, Part I, Line 7a, Column (f).
(4)
Unreimbursed Medicaid Net Community
7B(E) $
Enter the amount from Schedule H, Part I, Line 7b, Column (e).
(5)
Unreimbursed Medicaid Percent
7B(F)
Enter the percent from Schedule H, Part I, Line 7b, Column (f).
(6)
Unreimbursed Costs - Other Net Community
7C(E) $
Enter the amount from Schedule H, Part I, Line 7c, Column (e).
(7)
Unreimbursed Costs - Other Percent
7C(F)
Enter the percent from Schedule H, Part I, Line 7c, Column (f)
(8)
Total Financial Assistance Net Community
7D(E) $
Enter the amount from Schedule H, Part I, Line 7d, Column (e).
(9)
Total Financial Assistance
7D(F)
Enter the percent from Schedule H, Part I, Line 7d, Column (f).
(10)
Total Other Benefits Net Community
7J(E) $
Enter the amount from Schedule H, Part I, Line 7j, Column (e).
(11)
Total Other Benefits Percent
7J(F)
Enter the percent from Schedule H, Part I, Line 7j, Column (f).
(12)
Total Financial Assistance and Other Benefits Net Community
7K(E) $
Enter the amount from Schedule H, Part I, Line 7k, Column (e).
(13)
Total Financial Assistance and Other Benefits Percent
7K(F) $
Enter the percent from Schedule H, Part I, Line 7k, Column (f).
(14)
Report Bad Debt Expense
PT3 L1
Enter a yes or no from the yes/no box on Sch H, Part III, Line 1.
(15)
Bad Debt Expense Amount
L2 $
Enter the amount from Schedule H, Part III, Line 2.
(16)
Estimated Bad Debt Expense Amount
L3 $
Enter the amount from Schedule H, Part III, Line 3.
(17)
Revenue from Medicare
L5 $
Enter the amount from Schedule H, Part III, Line 5.
(18)
Medicare Allowable Costs
L6 $
Enter the amount from Schedule H, Part III, Line 6.
(19)
Medicare Surplus or Shortfall
L7 $
Enter the amount from Schedule H, Part III, Line 7.
(20)
Costing Methodology or Source Code
L8CD
Enter the edited code from the right of the boxes from Schedule H, Part III, Line 8.
(21)
Written Debt Collection Policy
L9A
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9a.
(22)
Collection Policy Contain Provisions
L9B
Enter a yes or no from the yes/no box on Schedule H, Part III, Line 9b.
Form 990 - Section 15, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
How Many Hospital Facilities Did Organization Operate
SECATOP
Enter the number shown in the Hospital Facilities area in the top left portion of Schedule H, Part V, Section A.
(3)
How Many Non-Hospital Facilities Did Organization Operate
SECCTOP
Enter the number shown in the Other Facilities area in the top portion of Schedule H, Part V, Section C.
(4)
Name of Facility
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(5)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(6)
Facility Line Number
LN#HOSP
Enter the number shown on the Line Number of Hospital Facility area on the top portion of Schedule H, Part V, Section B.
(7)
Conduct Community Health Needs Assessment
L1
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 1.
(8)
Definition of Community Served
L1A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(9)
Demographics of Community
L1B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1b is checked.
(10)
Existing Health Care Facilities and Resources
L1C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1c is checked.
(11)
How Data was Obtained
L1D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1d is checked.
(12)
Health Needs of Community
L1E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1e is checked.
(13)
Primary and Chronic Disease Needs
L1F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1f is checked.
(14)
Identifying and Prioritizing Health Needs
L1G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1g is checked.
(15)
Consulting with Persons Representing
L1H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1h is checked.
(16)
Information Gaps the Limit
L1I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1i is checked.
(17)
Other
L1J
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1j is checked.
(18)
Needs Assessment: 20XX
L2
Enter the two-digit year field from Schedule H, Part V, Section B, Line 2.
(19)
Hospital Facility Take Into Account Input
L3
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 3.
(20)
Conducted with one or More Other Hospital
L4
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 4.
(21)
Widely Available to Public
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(22)
Hospital Website
L5A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5a is checked.
(23)
Available Upon Request
L5B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5b is checked.
(24)
Other
L5C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5c is checked.
(25)
Adoption of Implementation Strategy
L6A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6a is checked.
(26)
Execution of Implementation Strategy
L6B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6b is checked.
(27)
Development of Community-Wide Community Benefit Plan
L6C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6c is checked.
(28)
Execution of Community-Wide Community Benefit Plan
L6D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6d is checked.
(29)
Inclusion of Community Benefit Section
L6E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6e is checked.
(30)
Adoption of Budget for Provision of Services
L6F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6f is checked.
(31)
Prioritization of Health Needs
L6G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6g is checked.
(32)
Prioritization of Services
L6H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6h is checked.
(33)
Other
L6I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6i is checked.
(34)
Hospital Facility Address All Needs Identified
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(35)
Excise Tax under Section 4959
L8A
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8a.
(36)
Did Organization File Form 4720
L8B
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8b.
(37)
4959 Tax Reported
L8C
ENTER
Enter the amount from Part V, Section B, Line 8c.
(38)
Eligibility Criteria for Financial Assistance
L9
Enter
Enter a yes or no from the yes/no box form Schedule H, Part V, Section B, Line 9.
(39)
Uses Federal Policy Guidelines (FPG) Free Care
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(40)
Free Care Percent
10%
Enter the 3-digit percent from Schedule H, Part V, Section B, Line 10, percent line.
Form 990 - Section 16, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
FPG Discounted Care
SCHH PTV SECB11
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 11.
(3)
Discounted Care Percent
11%
Enter the 3-digit percent from Sch H, Part V, Section B, Line 11.
(4)
Basis for Calculating Amounts Charged
12
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 12.
(5)
Income Level
12A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12a is checked.
(6)
Asset Level
12B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12b is checked.
(7)
Medical Indigency
12C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12c is checked.
(8)
Insurance Status
12D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12d is checked.
(9)
Uninsured Discount
12E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12e is checked.
(10)
Medicaid/medicare
12F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12f is checked.
(11)
State Regulation
12G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12g is checked.
(12)
Other
12H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12h is checked.
(13)
Method for Applying for Financial Assistance
13
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(14)
Measures to Publicize the Policy
14
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(15)
Policy Posted on Hospital Web Site
14A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14a is checked.
(16)
Policy Attached to Billing Invoices
14B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14b is checked.
(17)
Policy Posted in Emergency or Waiting Rooms
14C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14c is checked.
(18)
Policy Posted in Admissions Office
14D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14d is checked.
(19)
Policy Provided in Writing Upon Admission
14E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14e is checked.
(20)
Policy Available Upon Request
14F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14f is checked.
(21)
Other
14G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14g is checked.
(22)
Separate Billing and Collections Policy
15
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(23)
Actions Against Patient Reporting to Credit Agency
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(24)
Patient Lawsuits
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(25)
Patient Liens on Residences
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(26)
Patient Body Attachments
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(27)
Patient Other
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
Form 990 - Section 17, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Third Party Collection Actions
17
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(3)
Third Party Reporting to Credit Agency
17A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17a is checked.
(4)
Third Party Lawsuits
17B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17b is checked.
(5)
Third Party Liens on Residences
17C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17c is checked.
(6)
Third Party Body Attachments
17D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17d is checked.
(7)
Third Party Other
17E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17e is checked.
(8)
Notified Financial Assistance Upon Admission
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(9)
Notified Financial Assistance Prior to Discharge
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(10)
Notified Financial Assistance in Bills
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(11)
Documented its Determination
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(12)
Other
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
(13)
Written Policy to Emergency Medical Dare Policy
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(14)
Did Not Provide Care for Emergency Medical Conditions
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(15)
Did Not Have Policy Relating to Emergency Medical Care
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(16)
Limited Who Was Eligible
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(17)
Other
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(18)
Negotiated Commercial Insurance Rate
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(19)
Average of the Three Lowest Negotiated Commercial Insurance Rates
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(20)
Medicare Rate
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(21)
Other
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(22)
Charge Any of Its Patients
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(23)
Amount Equal to the Gross Charge
22
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 22.
Form 990 - Section 18, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Facility Line Number
LN#HOSP
Enter the number shown on the Line Number of Hospital Facility area on the top portion of Schedule H, Part V, Section B.
(5)
Conduct Community Health Needs Assessment
L1
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 1.
(6)
Definition of Community Served
L1A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(7)
Demographics of Community
L1B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1b is checked.
(8)
Existing Health Care Facilities and Resources
L1C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1c is checked.
(9)
How Data was Obtained
L1D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1d is checked.
(10)
Health Needs of Community
L1E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1e is checked.
(11)
Primary and Chronic Disease Needs
L1F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1f is checked.
(12)
Identifying and Prioritizing Health Needs
L1G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1g is checked.
(13)
Consulting with Persons Representing
L1H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1h is checked.
(14)
Information Gaps the Limit
L1I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1i is checked.
(15)
Other
L1J
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(16)
Needs Assessment: 20XX
L2
Enter the two-digit year field from Schedule H, Part V, Section B, Line 2.
(17)
Hospital Facility Take Into Account Input
L3
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 3.
(18)
Conducted with one or More Other Hospital
L4
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 4.
(19)
Widely Available to Public
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(20)
Hospital Website
L5A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5a is checked.
(21)
Available Upon Request
L5B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5b is checked.
(22)
Other
L5C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5c is checked.
(23)
Adoption of Implementation Strategy
L6A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6a is checked.
(24)
Execution of Implementation Strategy
L6B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6b is checked.
(25)
Development of Community-Wide Community Benefit Plan
L6C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6c is checked.
(26)
Execution of Community-Wide Community Benefit Plan
L6D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6d is checked.
(27)
Inclusion of Community Benefit Section
L6E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6e is checked.
(28)
Adoption of Budget for Provision of Services
L6F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6f is checked.
(29)
Prioritization of Health Needs
L6G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6g is checked.
(30)
Prioritization of Services
L6H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6h is checked.
(31)
Other
L6I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6i is checked.
(32)
Hospital Facility Address All Needs Identified
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(33)
Excise Tax Under Section 4959
L8A
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8a.
(34)
Did Organization File Form 4720
L8B
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8b.
(35)
4959 Tax Reported
L8C
ENTER
Enter the amount from Schedule H, Part V, Section B, Line 8c.
(36)
Eligibility Criteria for Financial Assistance
L9
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 9.
(37)
Uses Federal Policy Guidelines (FPG) Free Care
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(38)
Free Care Percent
10%
Enter the 3-digit percent from Schedule H, Part V, Section B, Line 10, percent line.
Form 990 - Section 19, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
FPG Discounted Care
SCHH PTV SECB11
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 11.
(3)
Discounted Care Percent
11%
Enter the 3-digit percent from Schedule H, Part V, Section B, Line 11.
(4)
Basis for Calculating Amounts Charged
12
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 12.
(5)
Income Level
12A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12a is checked.
(6)
Asset Level
12B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12b is checked.
(7)
Medical Indigency
12C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12c is checked.
(8)
Insurance Status
12D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12d is checked.
(9)
Uninsured Discount
12E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12e is checked.
(10)
Medicaid/medicare
12F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12f is checked.
(11)
State Regulation
12G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12g is checked.
(12)
Other
12H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12h is checked.
(13)
Method for Applying for Financial Assistance
13
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(14)
Measures to Publicize the Policy
14
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(15)
Policy Posted on Hospital Web Site
14A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14a is checked.
(16)
Policy Attached to Billing Invoices
14B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14b is checked.
(17)
Policy Posted in Emergency or Waiting Rooms
14C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14c is checked.
(18)
Policy Posted in Admissions Office
14D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14d is checked.
(19)
Policy Provided in Writing Upon Admission
14E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14e is checked.
(20)
Policy Available Upon Request
14F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14f is checked.
(21)
Other
14G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14g is checked.
(22)
Separate Billing and Collections Policy
15
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(23)
Actions Against Patient Reporting to Credit Agency
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(24)
Patient Lawsuits
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(25)
Patient Liens on Residences
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(26)
Patient Body Attachments
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(27)
Patient Other
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
Form 990 - Section 20, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Third Party Collection Actions
17
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(3)
Third Party Reporting to Credit Agency
17A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17a is checked.
(4)
Third Party Lawsuits
17B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17b is checked.
(5)
Third Party Liens on Residences
17C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17c is checked.
(6)
Third Party Body Attachments
17D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17d is checked.
(7)
Third Party Other
17E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17e is checked.
(8)
Notified Financial Assistance Upon Admission
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(9)
Notified Financial Assistance Prior to Discharge
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(10)
Notified Financial Assistance in Bills
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(11)
Documented its Determination
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(12)
Other
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
(13)
Written Policy to Emergency Medical Dare Policy
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(14)
Did Not Provide Care for Emergency Medical Conditions
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(15)
Did Not Have Policy Relating to Emergency Medical Care
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(16)
Limited Who Was Eligible
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(17)
Other
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(18)
Negotiated Commercial Insurance Rate
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(19)
Average of the Three Lowest Negotiated Commercial Insurance Rates
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(20)
Medicare Rate
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(21)
Other
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(22)
Charge Any of Its Patients
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(23)
Amount Equal to the Gross Charge
22
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 22.
Form 990 - Section 21, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Sec B.
(4)
Facility Line Number
LN#HOSP
Enter the number shown on the Line Number of Hospital Facility area on the top portion of Schedule H, Part V, Section B.
(5)
Conduct Community Health Needs Assessment
L1
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 1.
(6)
Definition of Community Served
L1A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(7)
Demographics of Community
L1B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1b is checked.
(8)
Existing Health Care Facilities and Resources
L1C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1c is checked.
(9)
How Data was Obtained
L1D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1d is checked.
(10)
Health Needs of Community
L1E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1e is checked.
(11)
Primary and Chronic Disease Needs
L1F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1f is checked.
(12)
Identifying and Prioritizing Health Needs
L1G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1g is checked.
(13)
Consulting with Persons Representing
L1H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1h is checked.
(14)
Information Gaps the Limit
L1I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1i is checked.
(15)
Other
L1J
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(16)
Needs Assessment: 20XX
L2
Enter the two-digit year field from Schedule H, Part V, Section B, Line 2.
(17)
Hospital Facility Take Into Account Input
L3
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 3.
(18)
Conducted with one or More Other Hospital
L4
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 4.
(19)
Widely Available to Public
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(20)
Hospital Website
L5A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5a is checked.
(21)
Available Upon Request
L5B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5b is checked.
(22)
Other
L5C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5c is checked.
(23)
Adoption of Implementation Strategy
L6A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6a is checked.
(24)
Execution of Implementation Strategy
L6B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6b is checked.
(25)
Development of Community-Wide Community Benefit Plan
L6C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6c is checked.
(26)
Execution of Community-Wide Community Benefit Plan
L6D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6d is checked.
(27)
Inclusion of Community Benefit Section
L6E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6e is checked.
(28)
Adoption of Budget for Provision of Services
L6F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6f is checked.
(29)
Prioritization of Health Needs
L6G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6g is checked.
(30)
Prioritization of Services
L6H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6h is checked.
(31)
Other
L6I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6i is checked.
(32)
Hospital Facility Address All Needs Identified
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(33)
Excise Tax Under Section 4959
L8A
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8a.
(34)
Did Organization File Form 4720
L8B
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8b.
(35)
4959 Tax Reported
L8C
ENTER
Enter the amount from Schedule H, Part V, Section B, Line 8c.
(36)
Eligibility Criteria for Financial Assistance
L9
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 9.
(37)
Uses Federal Policy Guidelines (FPG) Free Care
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(38)
Free Care Percent
10%
Enter the 3-digit percent from Schedule H, Part V, Section B, Line 10, percent line.
Form 990 - Section 22, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
FPG Discounted Care
SCHH PTV SECB11
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 11.
(3)
Discounted Care Percent
11%
Enter the 3-digit percent from Schedule H, Part V, Section B, Line 11.
(4)
Basis for Calculating Amounts Charged
12
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 12.
(5)
Income Level
12A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12a is checked.
(6)
Asset Level
12B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12b is checked.
(7)
Medical Indigency
12C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12c is checked.
(8)
Insurance Status
12D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12d is checked.
(9)
Uninsured Discount
12E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12e is checked.
(10)
Medicaid/medicare
12F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12f is checked.
(11)
State Regulation
12G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12g is checked.
(12)
Other
12H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12h is checked.
(13)
Method for Applying for Financial Assistance
13
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(14)
Measures to Publicize the Policy
14
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(15)
Policy Posted on Hospital Web Site
14A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14a is checked.
(16)
Policy Attached to Billing Invoices
14B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14b is checked.
(17)
Policy Posted in Emergency or Waiting Rooms
14C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14c is checked.
(18)
Policy Posted in Admissions Office
14D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14d is checked.
(19)
Policy Provided in Writing Upon Admission
14E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14e is checked.
(20)
Policy Available Upon Request
14F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14f is checked.
(21)
Other
14G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14g is checked.
(22)
Separate Billing and Collections Policy
15
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(23)
Actions Against Patient Reporting to Credit Agency
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(24)
Patient Lawsuits
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(25)
Patient Liens on Residences
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(26)
Patient Body Attachments
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(27)
Patient Other
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
Form 990 - Section 23, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Third Party Collection Actions
17
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(3)
Third Party Reporting to Credit Agency
17A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17a is checked.
(4)
Third Party Lawsuits
17B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17b is checked.
(5)
Third Party Liens on Residences
17C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17c is checked.
(6)
Third Party Body Attachments
17D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17d is checked.
(7)
Third Party Other
17E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17e is checked.
(8)
Notified Financial Assistance Upon Admission
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(9)
Notified Financial Assistance Prior to Discharge
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(10)
Notified Financial Assistance in Bills
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(11)
Documented its Determination
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(12)
Other
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
(13)
Written Policy to Emergency Medical Dare Policy
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(14)
Did Not Provide Care for Emergency Medical Conditions
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(15)
Did Not Have Policy Relating to Emergency Medical Care
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(16)
Limited Who Was Eligible
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(17)
Other
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(18)
Negotiated Commercial Insurance Rate
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(19)
Average of the Three Lowest Negotiated Commercial Insurance Rates
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(20)
Medicare Rate
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(21)
Other
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(22)
Charge Any of Its Patients
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(23)
Amount Equal to the Gross Charge
22
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 22.
Form 990 - Section 24, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Facility Line Number
LN#HOSP
Enter the number shown on the Line Number of Hospital Facility area on the top portion of Schedule H, Part V, Section B.
(5)
Conduct Community Health Needs Assessment
L1
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 1.
(6)
Definition of Community Served
L1A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(7)
Demographics of Community
L1B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1b is checked.
(8)
Existing Health Care Facilities and Resources
L1C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1c is checked.
(9)
How Data was Obtained
L1D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1d is checked.
(10)
Health Needs of Community
L1E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1e is checked.
(11)
Primary and Chronic Disease Needs
L1F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1f is checked.
(12)
Identifying and Prioritizing Health Needs
L1G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1g is checked.
(13)
Consulting with Persons Representing
L1H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1h is checked.
(14)
Information Gaps the Limit
L1I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1i is checked.
(15)
Other
L1J
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(16)
Needs Assessment: 20XX
L2
Enter the two-digit year field from Schedule H, Part V, Section B, Line 2.
(17)
Hospital Facility Take Into Account Input
L3
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 3.
(18)
Conducted with one or More Other Hospital
L4
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 4.
(19)
Widely Available to Public
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(20)
Hospital Website
L5A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5a is checked.
(21)
Available Upon Request
L5B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5b is checked.
(22)
Other
L5C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5c is checked.
(23)
Adoption of Implementation Strategy
L6A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6a is checked.
(24)
Execution of Implementation Strategy
L6B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6b is checked.
(25)
Development of Community-Wide Community Benefit Plan
L6C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6c is checked.
(26)
Execution of Community-Wide Community Benefit Plan
L6D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6d is checked.
(27)
Inclusion of Community Benefit Section
L6E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6e is checked.
(28)
Adoption of Budget for Provision of Services
L6F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6f is checked.
(29)
Prioritization of Health Needs
L6G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6g is checked.
(30)
Prioritization of Services
L6H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6h is checked.
(31)
Other
L6I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6i is checked.
(32)
Hospital Facility Address All Needs Identified
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(33)
Excise Tax Under Section 4959
L8A
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8a.
(34)
Did Organization File Form 4720
L8B
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8b.
(35)
4959 Tax Reported
L8C
ENTER
Enter the amount from Schedule H, Part V, Section B, Line 8c.
(36)
Eligibility Criteria for Financial Assistance
L9
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 9.
(37)
Uses Federal Policy Guidelines (FPG) Free Care
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(38)
Free Care Percent
10%
Enter the 3-digit percent from Schedule H, Part V, Section B, Line 10, percent line.
Form 990 - Section 25, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
FPG Discounted Care
SCHH PTV SECB11
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 11.
(3)
Discounted Care Percent
11%
Enter the 3-digit percent from Sch H, Part V, Section B, Line 11.
(4)
Basis for Calculating Amounts Charged
12
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 12.
(5)
Income Level
12A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12a is checked.
(6)
Asset Level
12B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12b is checked.
(7)
Medical Indigency
12C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12c is checked.
(8)
Insurance Status
12D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12d is checked.
(9)
Uninsured Discount
12E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12e is checked.
(10)
Medicaid/medicare
12F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12f is checked.
(11)
State Regulation
12G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12g is checked.
(12)
Other
12H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12h is checked.
(13)
Method for Applying for Financial Assistance
13
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(14)
Measures to Publicize the Policy
14
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(15)
Policy Posted on Hospital Web Site
14A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14a is checked.
(16)
Policy Attached to Billing Invoices
14B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14b is checked.
(17)
Policy Posted in Emergency or Waiting Rooms
14C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14c is checked.
(18)
Policy Posted in Admissions Office
14D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14d is checked.
(19)
Policy Provided in Writing Upon Admission
14E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14e is checked.
(20)
Policy Available Upon Request
14F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14f is checked.
(21)
Other
14G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14g is checked.
(22)
Separate Billing and Collections Policy
15
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(23)
Actions Against Patient Reporting to Credit Agency
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(24)
Patient Lawsuits
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(25)
Patient Liens on Residences
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(26)
Patient Body Attachments
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(27)
Patient Other
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
Form 990 - Section 26, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Third Party Collection Actions
17
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(3)
Third Party Reporting to Credit Agency
17A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17a is checked.
(4)
Third Party Lawsuits
17B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17b is checked.
(5)
Third Party Liens on Residences
17C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17c is checked.
(6)
Third Party Body Attachments
17D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17d is checked.
(7)
Third Party Other
17E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17e is checked.
(8)
Notified Financial Assistance Upon Admission
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(9)
Notified Financial Assistance Prior to Discharge
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(10)
Notified Financial Assistance in Bills
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(11)
Documented its Determination
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(12)
Other
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
(13)
Written Policy to Emergency Medical Dare Policy
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(14)
Did Not Provide Care for Emergency Medical Conditions
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(15)
Did Not Have Policy Relating to Emergency Medical Care
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(16)
Limited Who Was Eligible
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(17)
Other
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(18)
Negotiated Commercial Insurance Rate
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(19)
Average of the Three Lowest Negotiated Commercial Insurance Rates
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(20)
Medicare Rate
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(21)
Other
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(22)
Charge Any of Its Patients
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(23)
Amount Equal to the Gross Charge
22
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 22.
Form 990 - Section 27, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Name of Facility
BNAME
Enter the name as shown on the top portion of Schedule H, Part V, Section B.
(3)
Section B Facility Identification Number Code
BCODE
Enter the edited code from the right of Name of Hospital Facility on Schedule H, Part V, Section B.
(4)
Facility Line Number
LN#HOSP
Enter the number shown on the Line Number of Hospital Facility area on the top portion of Schedule H, Part V, Section B.
(5)
Conduct Community Health Needs Assessment
L1
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 1.
(6)
Definition of Community Served
L1A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(7)
Demographics of Community
L1B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1b is checked.
(8)
Existing Health Care Facilities and Resources
L1C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1c is checked.
(9)
How Data was Obtained
L1D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1d is checked.
(10)
Health Needs of Community
L1E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1e is checked.
(11)
Primary and Chronic Disease Needs
L1F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1f is checked.
(12)
Identifying and Prioritizing Health Needs
L1G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1g is checked.
(13)
Consulting with Persons Representing
L1H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1h is checked.
(14)
Information Gaps the Limit
L1I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1i is checked.
(15)
Other
L1J
Enter a "1" if the box on Schedule H, Part V, Section B, Line 1a is checked.
(16)
Needs Assessment: 20XX
L2
Enter the two-digit year field from Schedule H, Part V, Section B, Line 2.
(17)
Hospital Facility Take Into Account Input
L3
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 3.
(18)
Conducted with one or More Other Hospital
L4
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 4.
(19)
Widely Available to Public
L5
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 5.
(20)
Hospital Website
L5A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5a is checked.
(21)
Available Upon Request
L5B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5b is checked.
(22)
Other
L5C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 5c is checked.
(23)
Adoption of Implementation Strategy
L6A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6a is checked.
(24)
Execution of Implementation Strategy
L6B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6b is checked.
(25)
Development of Community-Wide Community Benefit Plan
L6C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6c is checked.
(26)
Execution of Community-Wide Community Benefit Plan
L6D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6d is checked.
(27)
Inclusion of Community Benefit Section
L6E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6e is checked.
(28)
Adoption of Budget for Provision of Services
L6F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6f is checked.
(29)
Prioritization of Health Needs
L6G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6g is checked.
(30)
Prioritization of Services
L6H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6h is checked.
(31)
Other
L6I
Enter a "1" if the box on Schedule H, Part V, Section B, Line 6i is checked.
(32)
Hospital Facility Address All Needs Identified
L7
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 7.
(33)
Excise Tax Under Section 4959
L8A
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8a.
(34)
Did Organization File Form 4720
L8B
ENTER
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 8b.
(35)
4959 Tax Reported
L8C
ENTER
Enter the amount from Schedule H, Part V, Section B, Line 8c.
(36)
Eligibility Criteria for Financial Assistance
L9
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 9.
(37)
Uses Federal Policy Guidelines (FPG) Free Care
L10
Enter a yes or a no from the yes/no box from Schedule H, Part V, Section B, Line 10.
(38)
Free Care Percent
10%
Enter the 3-digit percent from Schedule H, Part V, Section B, Line 10, percent line.
Form 990 - Section 28, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
FPG Discounted Care
SCHH PTV SECB11
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 11.
(3)
Discounted Care Percent
11%
Enter the 3-digit percent from Schedule H, Part V, Section B, Line 11.
(4)
Basis for Calculating Amounts Charged
12
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 12.
(5)
Income Level
12A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12a is checked.
(6)
Asset Level
12B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12b is checked.
(7)
Medical Indigency
12C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12c is checked.
(8)
Insurance Status
12D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12d is checked.
(9)
Uninsured Discount
12E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12e is checked.
(10)
Medicaid/medicare
12F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12f is checked.
(11)
State Regulation
12G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12g is checked.
(12)
Other
12H
Enter a "1" if the box on Schedule H, Part V, Section B, Line 12h is checked.
(13)
Method for Applying for Financial Assistance
13
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 13.
(14)
Measures to Publicize the Policy
14
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 14.
(15)
Policy Posted on Hospital Web Site
14A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14a is checked.
(16)
Policy Attached to Billing Invoices
14B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14b is checked.
(17)
Policy Posted in Emergency or Waiting Rooms
14C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14c is checked.
(18)
Policy Posted in Admissions Office
14D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14d is checked.
(19)
Policy Provided in Writing Upon Admission
14E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14e is checked.
(20)
Policy Available Upon Request
14F
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14f is checked.
(21)
Other
14G
Enter a "1" if the box on Schedule H, Part V, Section B, Line 14g is checked.
(22)
Separate Billing and Collections Policy
15
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 15.
(23)
Actions Against Patient Reporting to Credit Agency
16A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16a is checked.
(24)
Patient Lawsuits
16B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16b is checked.
(25)
Patient Liens on Residences
16C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16c is checked.
(26)
Patient Body Attachments
16D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16d is checked.
(27)
Patient Other
16E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 16e is checked.
Form 990 - Section 29, Schedule H (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Third Party Collection Actions
17
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 17.
(3)
Third Party Reporting to Credit Agency
17A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17a is checked.
(4)
Third Party Lawsuits
17B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17b is checked.
(5)
Third Party Liens on Residences
17C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17c is checked.
(6)
Third Party Body Attachments
17D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17d is checked.
(7)
Third Party Other
17E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 17e is checked.
(8)
Notified Financial Assistance Upon Admission
18A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18a is checked.
(9)
Notified Financial Assistance Prior to Discharge
18B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18b is checked.
(10)
Notified Financial Assistance in Bills
18C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18c is checked.
(11)
Documented its Determination
18D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18d is checked.
(12)
Other
18E
Enter a "1" if the box on Schedule H, Part V, Section B, Line 18e is checked.
(13)
Written Policy to Emergency Medical Dare Policy
19
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 19.
(14)
Did Not Provide Care for Emergency Medical Conditions
19A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19a is checked.
(15)
Did Not Have Policy Relating to Emergency Medical Care
19B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19b is checked.
(16)
Limited Who Was Eligible
19C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19c is checked.
(17)
Other
19D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 19d is checked.
(18)
Negotiated Commercial Insurance Rate
20A
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20a is checked.
(19)
Average of the Three Lowest Negotiated Commercial Insurance Rates
20B
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20b is checked.
(20)
Medicare Rate
20C
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20c is checked.
(21)
Other
20D
Enter a "1" if the box on Schedule H, Part V, Section B, Line 20d is checked.
(22)
Charge Any of Its Patients
21
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 21.
(23)
Amount Equal to the Gross Charge
22
Enter a yes or no from the yes/no box from Schedule H, Part V, Section B, Line 22.
Form 990 - Section 30, Schedules L & R (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Excess Benefit Transactions
PT1 RTMAR
Enter the edited digit from the right margin of Schedule L, Part 1.
(3)
Approved by Board or Committee
PT2 RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
(4)
Interest, Annuities, Royalties, Yes/No Box
SCHR PT51A
Enter a yes or a no from the yes/no box from Schedule R, Part V, Line 1a.
Form 990 - Section 01 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generates the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present. (a) If not present, press
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
See standard rules in IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
CP 411–414, 420–429, edited in the area around the "Tax Period" .
(10)
Type of Organization
BOXF RT
Enter the edited digit from the right margin of box F.
(11)
Group Code
BOXH RT
Enter the edited code from the right margin of box H.
(12)
Computer Condition Codes
CCC
Enter the edited characters as shown on dotted portion of Lines 1a —- 1c. If a Condition Code is illegible, enter a "#" in its place.
(13)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM 3.24.38 for special instructions.
If the Type of Organization is a "9" , and the ""9" is underlined" , don't end the document. Continue transcribing the return.
If Type of Organization is a "9" , and the "9" is NOT underlined, press
If a "G" Condition Code is present in Section 01 E-12 and the return is non-remittance, end the document after this element.
(14)
Box J 501(c) #
501C#
Enter the edited 2 digit code from the lower right corner of the entity portion.
(15)
Box M Checkbox
M RTMAR
Enter the edited code from the right margin of Line 1d.
(16)
In Care of Name Line
C/O NAME
Enter the in-care-of name, if shown.
Note:¶
Downstream processing generates the (%) sign.
(17)
Foreign Address
FGN ADD
Enter the foreign street address, if shown. See IRM 3.24.38 for additional instructions.
(18)
Street Address
ADDR
Enter the street address from the address line.
See IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information, even if prompted to do so. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(19)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(20)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.)
(21)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
Form 990 - Section 02, Form 5800 - Edit Sheet (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and the return is a remittance, Press
If the Type of Organization is "9" from Section 01 E–10 and the " 9" is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is "9" , and the "9" is NOT underlined, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800, in MMDDYY format. (a) For special instructions, see IRM 3.24.38.
(7)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990 - Section 03 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY EXCEPT FOR E–(2).
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
If the ERS Action Code is in the "600" series, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Total Contributions, Gifts/Grants
L1E $
Enter the amount from Part I, Line 1e.
(4)
Program Service Revenue
LN2 $
Enter the amount from Part I, Line 2.
(5)
Membership Dues and Assessments
LN3 $
Enter the amount from Part I, Line 3.
(6)
Interest on Savings
LN4 $
Enter the amount from Part I, Line 4.
(7)
Dividends and Interest
LN5 $
Enter the amount from Part I, Line 5.
(8)
Gross Rents
L6A $
Enter the amount from Part I, Line 6a.
(9)
Minus Rental Expenses
L6B $
Enter the amount from Part I, Line 6b.
(10)
Net Rental Income (Loss)
L6C $
Enter the amount from Part I, Line 6c.
(11)
Other Investment Income
LN7 $
Enter the amount from Part I, Line 7.
(12)
Gross Amt Sale of Assets (Securities)
8A LF $
Enter the amount from Part I, Line 8a, Securities.
(13)
Gross Amt Sale of Assets (Other)
8A RT $
Enter the amount from Part I, Line 8a, Other.
(14)
Cost or Other Basis (Securities)
8B LF $
Enter the amount from Part I, Line 8b, Securities.
(15)
Minus Cost or Other Basis (Other)
8B RT $
Enter the amount from Part I, Line 8b, Other.
(16)
Gain/Loss Sale of Assets (Securities)
8C LF $
Enter the amount from Part I, Line 8c, Securities.
(17)
Gain/Loss Sale of Assets (Other)
8C RT $
Enter the amount from Part I, Line 8c, Other.
(18)
Special Events/Gaming
9CKBX
Enter a "1" if the box is checked on Part I, Line 9.
(19)
Gross Revenue (Fundraising)
9A RT $
Enter the amount from Part I, Line 9a.
(20)
Minus Direct Expenses
L9B $
Enter the amount from Part I, Line 9b.
(21)
Net Income (Fundraising)
L9C $
Enter the amount from Part I, Line 9c.
(22)
Gross Sales Minus Returns
10A $
Enter the amount from Part I, Line 10a.
(23)
Minus Cost of Goods Sold
10B $
Enter the amount from Part I, Line 10b.
(24)
Gross Profit (Loss)
10C $
Enter the amount from Part I, Line 10c.
(25)
Other Revenue
L11 $
Enter the amount from Part I, Line 11.
(26)
Total Revenue
L12 $
Enter the amount from Part I, Line 12.
(27)
Program Services
L13 $
Enter the amount from Part I, Line 13.
(28)
Fundraising
L15 $
Enter the amount from Part I, Line 15.
(29)
Payments to Affiliates
L16 $
Enter the amount from Part I, Line 16.
(30)
Total Expenses
L17 $
Enter the amount from Part I, Line 17.
(31)
Excess for Year
L18 $
Enter the amount from Part I, Line 18.
(32)
Other Changes in Net Assets
L20 $
Enter the amount from Part I, Line 20.
(33)
Net Assets or Fund Balances (EOY)
L21 $
Enter the amount from Part I, Line 21.
Form 990 - Section 04 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
IRI Codes
PG2TOP
Enter the edited digits from the top of page 2.
(3)
Grants From Donor Advised Funds
22AA $
Enter the amount from Part II, Line 22A, Column (A).
(4)
Donor Advised Funds Checkbox
22ACKBX
Enter a "1" if the box on Line 22a is checked.
(5)
Other Grants & Allocations
22BA $
Enter the amount from Part II, Line 22b, Column (A).
(6)
Other Foreign Grants Checkbox
22BCKBX
Enter a "1" if the box on Line 22b is checked.
(7)
Specific Assistance
23A $
Enter the amount from Part II, Line 23, Column (A).
(8)
Benefits To/For Members
24A $
Enter the amount from Part II, Line 24, Column (A).
(9)
Compensation of Current Officers
25AA $
Enter the amount from Part II, Line 25a, Column (A).
(10)
Compensation of Former Officers
25BA $
Enter the amount from Part II, Line 25b, Column (A).
(11)
Compensation and Other Distributions
25CA $
Enter the amount from Part II, Line 25c, Column (A).
(12)
Other Salaries and Wages
26A $
Enter the amount from Part II, Line 26, Column (A).
(13)
Pension Plan Contributions
27A $
Enter the amount from Part II, Line 27, Column (A).
(14)
Other Employee Benefits
28A $
Enter the amount from Part II, Line 28, Column (A).
(15)
Payroll Taxes
29A $
Enter the amount from Part II, Line 29, Column (A).
(16)
Professional Fund Raising Fees
30AD $
Enter the amount from Part II, Line 30, Column (A) or Column (D). (a) If both are present, enter the amount from Column (A).
(17)
Accounting Fees
31A $
Enter the amount from Part II, Line 31, Column (A).
(18)
Legal Fees
32A $
Enter the amount from Part II, Line 32, Column (A).
(19)
Supplies
33A $
Enter the amount from Part II, Line 33, Column (A).
(20)
Telephone
34A $
Enter the amount from Part II, Line 34, Column (A).
(21)
Postage & Shipping
35A $
Enter the amount from Part II, Line 35, Column (A).
(22)
Occupancy
36A $
Enter the amount from Part II, Line 36, Column (A).
(23)
Equipment Rental and Maintenance
37A $
Enter the amount from Part II, Line 37, Column (A).
(24)
Printing & Publications
38A $
Enter the amount from Part II, Line 38, Column (A).
(25)
Travel
39A $
Enter the amount from Part II, Line 39, Column (A).
(26)
Conferences, Conventions & Meetings
40A $
Enter the amount from Part II, Line 40, Column (A).
(27)
Interest
41A $
Enter the amount from Part II, Line 41, Column (A).
(28)
Depreciation, Depletion
42A $
Enter the amount from Part II, Line 42, Column (A).
(29)
Other Expenses a
43AA $
Enter the amount from Part II, Line 43a, Column (A).
(30)
Other Expenses b
43BA $
Enter the amount from Part II, Line 43b, Column (A).
(31)
Other Expenses c
43CA $
Enter the amount from Part II, Line 43c, Column (A).
(32)
Other Expenses d
43DA $
Enter the amount from Part II, Line 43d, Column (A).
(33)
Other Expenses e
43EA $
Enter the amount from Part II, Line 43e, Column (A).
(34)
Total Expenses
44A $
Enter the amount from Part II, Line 44, Column (A).
Form 990 - Section 05 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash (BOY)
45A $
Enter the amount from Part IV, Line 45, Column (A).
(3)
Cash (EOY)
45B $
Enter the amount from Part IV, Line 45, Column (B).
(4)
Savings/Temporary Investments (BOY)
46A $
Enter the amount from Part IV, Line 46, Column (A).
(5)
Savings/Temporary Investments (EOY)
46B $
Enter the amount from Part IV, Line 46, Column (B).
(6)
Accounts Receivable (BOY)
47CA $
Enter the amount from Part IV, Line 47c, Column (A).
(7)
Accounts Receivable (EOY)
47CB $
Enter the amount from Part IV, Line 47c, Column (B).
(8)
Pledges Receivable (BOY)
48CA $
Enter the amount from Part IV, Line 48c, Column (A).
(9)
Pledges Receivable (EOY)
48CB $
Enter the amount from Part IV, Line 48c, Column (B).
(10)
Grants Receivable (BOY)
49A $
Enter the amount from Part IV, Line 49, Column (A).
(11)
Grants Receivable (EOY)
49B $
Enter the amount from Part IV, Line 49, Column (B).
(12)
Current and Former Receivables (BOY)
50AA $
Enter the amount from Part IV, Line 50a, Column (A).
(13)
Current and Former Receivables (EOY)
50AB $
Enter the amount from Part IV, Line 50a, Column (B).
(14)
Receivables From Disqualified Persons (BOY)
50BA $
Enter the amount from Part IV, Line 50b, Column (A).
(15)
Receivables From Disqualified Persons (EOY)
50BB $
Enter the amount from Part IV, Line 50b, Column (B).
(16)
Other Notes/Loans (BOY)
51CA $
Enter the amount from Part IV, Line 51c, Column (A).
(17)
Other Notes/Loans (EOY)
51CB $
Enter the amount from Part IV, Line 51c, Column (B).
(18)
Inventories for Sale (BOY)
52A $
Enter the amount from Part IV, Line 52, Column (A).
(19)
Inventories For Sale (EOY)
52B $
Enter the amount from Part IV, Line 52, Column (B).
(20)
Prepaid Expenses (BOY)
53A $
Enter the amount from Part IV, Line 53, Column (A).
(21)
Prepaid Expenses (EOY)
53B $
Enter the amount from Part IV, Line 53, Column (B).
(22)
Investments - Publicly Traded Securities (BOY)
54AA $
Enter the amount from Part IV, Line 54a, Column (A).
(23)
Investments - Publicly Traded Securities (EOY)
54AB $
Enter the amount from Part IV, Line 54a, Column (B).
(24)
Investments - Other Securities (BOY)
54BA $
Enter the amount from Part IV, Line 54b, Column (A).
(25)
Investments - Other Securities (EOY)
54BB $
Enter the amount from Part IV, Line 54b, Column (B).
(26)
Investments-Land (BOY)
55CA $
Enter the amount from Part IV, Line 55c, Column (A).
(27)
Investments-Land (EOY)
55CB $
Enter the amount from Part IV, Line 55c, Column (B).
(28)
Other Investments (BOY)
56A $
Enter the amount from Part IV, Line 56, Column (A).
(29)
Other Investments (EOY)
56B $
Enter the amount from Part IV, Line 56, Column (B).
(30)
Land/Buildings (BOY)
57CA $
Enter the amount from Part IV, Line 57c, Column (A).
(31)
Land/Buildings (EOY)
57CB $
Enter the amount from Part IV, Line 57c, Column (B).
(32)
Other Assets (BOY)
58A $
Enter the amount from Part IV, Line 58, Column (A).
(33)
Other Assets (EOY)
58B $
Enter the amount from Part IV, Line 58, Column (B).
(34)
Total Assets (BOY)
59A $
Enter the amount from Part IV, Line 59, Column (A).
(35)
Total Assets (EOY)
59B $
Enter the amount from Part IV, Line 59, Column (B).
Form 990 - Section 06 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Accounts Payable (BOY)
60A $
Enter the amount from Part IV, Line 60, Column (A).
(3)
Accounts Payable (EOY)
60B $
Enter the amount from Part IV, Line 60, Column (B).
(4)
Grants Payable (BOY)
61A $
Enter the amount from Part IV, Line 61, Column (A).
(5)
Grants Payable (EOY)
61B $
Enter the amount from Part IV, Line 61, Column (B).
(6)
Deferred Revenue (BOY)
62A $
Enter the amount from Part IV, Line 62, Column (A).
(7)
Deferred Revenue (EOY)
62B $
Enter the amount from Part IV, Line 62, Column (B).
(8)
Loans (BOY)
63A $
Enter the amount from Part IV, Line 63, Column (A).
(9)
Loans (EOY)
63B $
Enter the amount from Part IV, Line 63, Column (B).
(10)
Tax-Exempt Bond Liabilities (BOY)
64AA $
Enter the amount from Part IV, Line 64a, Column (A).
(11)
Tax-Exempt Bond Liabilities (EOY)
64AB $
Enter the amount from Part IV, Line 64a, Column (B).
(12)
Mortgages/Other Notes (BOY)
64BA $
Enter the amount from Part IV, Line 64b, Column (A).
(13)
Mortgages/Other Notes (EOY)
64BB $
Enter the amount from Part IV, Line 64b, Column (B).
(14)
Other Liabilities (BOY)
65A $
Enter the amount from Part IV, Line 65, Column (A).
(15)
Other Liabilities (EOY)
65B $
Enter the amount from Part IV, Line 65, Column (B).
(16)
Total Liabilities (BOY)
66A $
Enter the amount from Part IV, Line 66, Column (A).
(17)
Total Liabilities (EOY)
66B $
Enter the amount from Part IV, Line 66, Column (B).
(18)
Retained Earnings (BOY)
72A $
Enter the amount from Part IV, Line 72, Column (A).
(19)
Retained Earnings (EOY)
72B $
Enter the amount from Part IV, Line 72, Column (B).
(20)
Total Fund Balance/Net Assets (BOY)
73A $
Enter the amount from Part IV, Line 73, Column (A).
(21)
Total Fund Balance/Net Assets (EOY)
73B $
Enter the amount from Part IV, Line 73, Column (B).
Form 990 - Section 07 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Voting Officers
75A
Enter the number from Part V-A, Line 75a.
(3)
Are there Relationships?
75B
Enter a yes or no from the yes/no box from Part V-A, Line 75b.
(4)
Was Compensation Received?
75C
Enter a yes or no from the yes/no box from Part V-A, Line 75c.
(5)
Compensation/Benefits Code
VBRTMAR
Enter the edited code from the bottom right margin of Part V-B.
(6)
Did you Make Changes to Activities/Methods?
76
Enter a yes or no from the yes/no box from Part VI, Line 76.
(7)
Were any change made?
77
Enter a yes or no from the yes/no box from Part VI, Line 77.
(8)
Did you have unrelated business?
78A
Enter a yes or no from the yes/no box from Part VI, Line 78a.
(9)
If yes, did you file Form 990-T?
78B
Enter a yes or no from the yes/no box from Part VI, Line 78b.
(10)
Was there a liquidation?
79
Enter a yes or no from the yes/no box from Part VI, Line 79.
(11)
Are you related?
80A
Enter a yes or no from the yes/no box from Part VI, Line 80a.
(12)
Political Expenditures
81A $
Enter the amount from Part VI, Line 81a.
(13)
Did you file Form 1120-POL?
81B
Enter a yes or no from the yes/no box from Part VI, Line 81b.
(14)
Section 501(c)(5) or (6) Organization?
85A
Enter a yes or no from te yes/no box from Part VI, Line 85a.
(15)
Did the Organization Make Lobbying Expenditures?
85B
Enter a yes or no from the yes/no box from Part VI, Line 85b.
(16)
Dues/Assessments & Similar Amounts
85C $
Enter the amount from Part VI, Line 85c.
(17)
Section 162(e) Lobbying
85D $
Enter the amount from Part VI, Line 85d.
(18)
Aggregate Non-deductible
85E $
Enter the amount from Part VI, Line 85e.
(19)
Taxable Amount/Lobbying
85F $
Enter the amount from Part VI, Line 85f.
(20)
Does the Organization Elect?
85G
Enter a yes or no from the yes/no box from Part VI, Line 85g.
(21)
If Section 6033(e)(1)(A)
85H
Enter a yes or no from the yes/no box from Part VI, Line 85h.
(22)
501(c)(7) Initiation Fees
86A $
Enter the amount from Part VI, Line 86a.
(23)
Gross Receipts Amount
86B $
Enter the amount from Part VI, Line 86b.
(24)
Gross Income/Members
87A $
Enter the amount from Part VI, Line 87a.
(25)
Gross Income/Other Sources
87B $
Enter the amount from Part VI, Line 87b.
(26)
At Any Time During the Year
88A
Enter a yes or no from the yes/no box from Part VI, Line 88a.
(27)
Did You Have Interest in Controlled Entity?
88B
Enter a yes or no from the yes/no box from Part VI, Line 88b.
(28)
501(c)(3) and 501(c)(4)
89B
Enter a yes or no from the yes/no box from Part VI, Line 89b.
(29)
Did You Acquire Direct/Indirect Interest?
89F
Enter a yes or no from the yes/no box from Part VI, Line 89f.
(30)
Did you have Foreign Bank Accounts?
91B
Enter a yes or no from the yes/no box from Part VI, Line 91b
(31)
Did you have a Foreign Office?
91C
Enter a yes or no from the yes/no box from Part VI, Line 91c.
(32)
Section 4947(a)(1) Trust Filing 990?
92
Enter the code edited to the right of Part VI, Line 92.
Form 990 - Section 08 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Program Service a (D)
93AD $
Enter the amount from Part VII, Line 93a, Column (D).
(3)
Program Service a (E)
93AE $
Enter the amount from Part VII, Line 93a, Column (E).
(4)
Program Service b (D)
93BD $
Enter the amount from Part VII, Line 93b, Column (D).
(5)
Program Service b (E)
93BE $
Enter the amount from Part VII, Line 93b, Column (E).
(6)
Program Service c (D)
93CD $
Enter the amount from Part VII, Line 93c, Column (D).
(7)
Program Service c (E)
93CE $
Enter the amount from Part VII, Line 93c, Column (E).
(8)
Program Service d (D)
93DD $
Enter the amount from Part VII, Line 93d, Column (D).
(9)
Program Service d (E)
93DE $
Enter the amount from Part VII, Line 93d, Column (E).
(10)
Program Service e (D)
93ED $
Enter the amount from Part VII, Line 93e, Column (D).
(11)
Program Service e (E)
93EE $
Enter the amount from Part VII, Line 93e, Column (E).
(12)
Medicare/Medicaid (D)
93FD $
Enter the amount from Part VII, Line 93f, Column (D).
(13)
Medicare/Medicaid (E)
93FE $
Enter the amount from Part VII, Line 93f, Column (E).
(14)
Fees and Contracts (D)
93GD $
Enter the amount from Part VII, Line 93g, Column (D).
(15)
Fees and Contracts (E)
93GE $
Enter the amount from Part VII, Line 93g, Column (E).
(16)
Membership Dues (D)
94D $
Enter the amount from Part VII, Line 94, Column (D).
(17)
Membership Dues (E)
94E $
Enter the amount from Part VII, Line 94, Column (E).
(18)
Interest on Savings (D)
95D $
Enter the amount from Part VII, Line 95, Column (D).
(19)
Interest on Savings (E)
95E $
Enter the amount from Part VII, Line 95, Column (E).
(20)
Dividends and Interest (D)
96D $
Enter the amount from Part VII, Line 96, Column (D).
(21)
Dividends & Interest (E)
96E $
Enter the amount from Part VII, Line 96, Column (E).
(22)
Debt-Financed Property (D)
97AD $
Enter the amount from Part VII, Line 97a, Column (D).
(23)
Debt-Financed Property (E)
97AE $
Enter the amount from Part VII, Line 97a, Column (E).
(24)
Non Debt-Financed (D)
97BD $
Enter the amount from Part VII, Line 97b, Column (D).
(25)
Non Debt-Financed (E)
97BE $
Enter the amount from Part VII, Line 97b, Column (E).
(26)
Non Rental Income/Loss (D)
98D $
Enter the amount from Part VII, Line 98, Column (D)
(27)
Non Rental Income/Loss (E)
98E $
Enter the amount from Part VII, Line 98, Column (E).
(28)
Other Investments (D)
99D $
Enter the amount from Part VII, Line 99, Column (D).
(29)
Other Investments (E)
99E $
Enter the amount from Part VII, Line 99, Column (E).
(30)
Gain/Loss From Sales (D)
100D $
Enter the amount from Part VII, Line 100, Column (D).
(31)
Gain/Loss From Sales (E)
100E $
Enter the amount from Part VII, Line 100, Column (E).
(32)
Net Income/Loss Property (D)
101D $
Enter the amount from Part VII, Line 101, Column (D).
(33)
Net Income/Loss Property (E)
101E $
Enter the amount from Part VII, Line 101, Column (E).
(34)
Gross Profit/Loss Sales (D)
102D $
Enter the amount from Part VII, Line 102, Column D.
(35)
Gross Profit/Loss Sales (E)
102E $
Enter the amount from Part VII, Line 102, Column (E).
(36)
Did the Organization Receive any Funds?
X(A)
Enter a yes or no from the yes/no box from Part X, Line (a).
(37)
Did the Organization Pay any Premiums?
X(B)
Enter a yes or no from the yes/no box from Part X, Line (b).
(38)
Did the Organization Make Any Transfers to a Controlled Entity?
XI106
Enter a yes or no from the yes/no box from Part XI, Line 106.
(39)
Did the Organization Receive Any Transfers From a Controlled Entity?
107
Enter a yes or no from the yes/no box from Part XI, Line 107.
(40)
Did the Organization Have a Binding Contract as of 08/17/2006?
108
Enter a yes or no from the yes/no box from Part XI, Line 108.
(41)
Preparation Code
PREP
Enter the edited code from the right of the preparer PTIN Line.
(42)
Preparer PTIN
PTIN
Enter the Preparer's PTIN.
(43)
Preparer's EIN
PEIN
Enter the preparer's EIN.
Form 990 - Section 09, Schedule A (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY
(2)
Question 1 Part III
LN1
Enter the edited digit to the right of Part III, Line 1.
If un-edited, enter a yes or no from the yes/no box from Part III, Line 1.
(3)
Legislative Activities
LN1 $
Enter the amount from Part III, Line 1, next to the $.
(4)
Was there a Sale, Exchange or Lease of Property?
L2A
Enter a yes or no from the yes/no box from Part III, Line 2a.
(5)
Did you Lend Money or Other Credit?
L2B
Enter a yes or no from the yes/no box from Part III, Line 2b.
(6)
Did you Furnish Goods, Services or Facilities?
L2C
Enter a yes or no from the yes/no box from Part III, Line 2c.
(7)
Did you make Payment Compensation?
L2D
Enter a yes or no from the yes/no box from Part III, Line 2d.
(8)
Did you Transfer Income or Assets?
L2E
Enter a yes or no from the yes/no box from Part III, Line 2e.
(9)
Do you Make Grants/Scholarships?
L3A
Enter a yes or no from the yes/no box from Part III, Line 3a.
(10)
Did you Have a Section 403(b) Annuity Plan?
L3B
Enter a yes or no from the yes/no box from Part III, Line 3b.
(11)
Did you Receive or Hold Easement - Section 170(h)?
L3C
Enter a yes or no from the yes/no box from Part III, Line 3c.
(12)
Do you Provide Credit Counseling?
L3D
Enter a yes or no from the yes/no box from Part III, Line 3d.
(13)
Did you Maintain any Donor Advised Funds?
L4A
Enter a yes or no from the yes/no box from Part III, Line 4a.
(14)
Did you Make any Taxable Distributions?
L4B
Enter a yes or no from the yes/no box from Part III, Line 4b.
(15)
Did you Make a Distribution – Section 4967?
L4C
Enter a yes or no from the yes/no box from Part III, Line 4c.
(16)
Enter the Total Number of Donor Advised Funds
L4D
Enter the number from Part III, Line 4d.
(17)
Enter the Aggregate Value of Assets
L4E $
Enter the amount from Part III, Line 4e.
(18)
Part IV Non-Private Foundation
IVRTMAR
Enter the edited code from the RIGHT margin of Part IV.
(19)
Total Amount of Support
13E $
Enter the amount from Part IV, Line 13, Column (e).
(20)
Gifts, Contributions, Grants
15E $
Enter the amount from Part IV-A, Line 15, Column (e).
(21)
Membership Fees
16E $
Enter the amount from Part IV-A, Line 16, Column (e).
(22)
Gross Receipts/Admissions
17E $
Enter the amount from Part IV-A, Line 17, Column (e).
(23)
Gross Income/Interest/Dividends
18E $
Enter the amount from Part IV-A, Line 18, Column (e).
(24)
Tax Revenues Levied
20E $
Enter the amount from Part IV-A, Line 20, Column (e).
(25)
Value of Services/Facilities Furnished
21E $
Enter the amount from Part IV-A, Line 21, Column (e).
(26)
Total Lines 15–22
23E $
Enter the amount from Part IV-A, Line 23, Column (e).
(27)
Line 23 Minus 17
24E $
Enter the amount from Part IV-A, Line 24, Column (e).
Form 990 - Section 10, Schedule A (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
If a large edited X is present through Part V or Part V is blank, don't enter this section.
(2)
Do you have a racially?
V29
Enter a yes or no from the yes/no box on Part V, Line 29.
(3)
Do you include?
30
Enter a yes or no from the yes/no box on Part V, Line 30.
(4)
Have you publicized?
31
Enter a yes or no from the yes/no box on Part V, Line 31.
(5)
Records indicating?
32A
Enter a yes or no from the yes/no box on Part V, Line 32a.
(6)
Records documenting?
32B
Enter a yes or no from the yes/no box on Part V, Line 32b.
(7)
Copies of all catalogues?
32C
Enter a yes or no from the yes/no box on Part V, Line 32c.
(8)
Copies of all material?
32D
Enter a yes or no from the yes/no box on Part V, Line 32d.
(9)
Students' rights?
33A
Enter a yes or no from the yes/no box on Part V, Line 33a.
(10)
Admission Policies?
33B
Enter a yes or no from the yes/no box on Part V, Line 33b.
(11)
Employment of faculty?
33C
Enter a yes or no from the yes/no box on Part V, Line 33c.
(12)
Scholarships?
33D
Enter a yes or no from the yes/no box on Part V, Line 33d.
(13)
Educational policies?
33E
Enter a yes or no from the yes/no box on Part V, Line 33e.
(14)
Use of facilities?
33F
Enter a yes or no from the yes/no box on Part V, Line 33f.
(15)
Athletic programs?
33G
Enter a yes or no from the yes/no box on Part V, Line 33g.
(16)
Other extracurricular activities?
33H
Enter a yes or no from the yes/no box on Part V, Line 33h.
(17)
Does Organization Certify?
35
Enter a yes or a no from the yes/no box on Part V, Line 35.
(18)
Signature Code
SIGN
Enter the code edited in the lower right margin of page 5, Schedule A.
Form 990 - Section 11, Schedule A (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
Total (Grass Roots) Expenditures
36B $
Enter the amount from Part VI-A, Line 36, Column (b).
(3)
Total Lobbying Expenses
37B $
Enter the amount from Part VI-A, Line 37, Column (b).
(4)
Other Exempt Purposes Expenses
39B $
Enter the amount from Part VI-A, Line 39, Column (b).
(5)
Lobbying Nontaxable Amount
41B $
Enter the amount from Part VI-A, Line 41, Column (b).
(6)
Grass Roots Nontaxable Amount
42B $
Enter the amount from Part VI-A, Line 42, Column (b).
(7)
Excess of Line 36 over Line 42
43B $
Enter the amount from Part VI-A, Line 43, Column (b).
(8)
Excess of Line 38 over Line 41
44B $
Enter the amount from Part VI-A, Line 44, Column (b).
(9)
Part VI-B, Line i, Total
VIBLNI $
Enter the amount from Part VI-B, Line i.
Form 990 - Section 12, Schedule A (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash transfers?
51AI
Enter a yes or no from the yes/no box on Part VII, Line 51a(i).
(3)
Other assets?
AII
Enter a yes or no from the yes/no box on Part VII, Line 51a(ii).
(4)
Sales of assets?
51BI
Enter a yes or no from the yes/no box on Part VII, Line 51b(i).
(5)
Purchases of assets?
BII
Enter a yes or no from the yes/no box on Part VII, Line 51b(ii).
(6)
Rental?
BIII
Enter a yes or no from the yes/no box on Part VII, Line 51b(iii).
(7)
Reimbursement?
BIV
Enter a yes or no from the yes/no box on Part VII, Line 51b(iv).
(8)
Loans?
BV
Enter a yes or no from the yes/no box on Part VII, Line 51b(v).
(9)
Performance of services?
BVI
Enter a yes or no from the yes/no box on Part VII, Line 51b(vi).
(10)
Sharing?
51C
Enter a yes or no from the yes/no box on Part VII, Line 51c.
Form 990-EZ - Section 01 (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section 01 always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generates the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present. (a) If not present, press
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
See standard rules in IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter Y or N as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under title of form.
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
(10)
Type of Organization
BOXGRT
Enter the edited code from right margin of box F. If the edit sheet isn't present, enter the Type of Organization from the right margin of Lines C, D or E.
(11)
Computer Condition Codes
CCC
Enter the edited characters from the dotted portion of Lines 1–3. If a Condition Code is illegible, enter a # in its place.
(12)
Return Processing Code
01RPC
Enter the edited codes on Page 1, in the right margin next to line 1.
(13)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM 3.24.38 for special instructions.
If Type of Organization is a "9" , and the 9 is underlined, don't end the document. Continue transcribing the return.
If the Type of Organization is a "9" and the "9" is NOT underlined, press
If a "G" Condition Code is present and the return is a non-remittance, end the document after this element.
(14)
Box J 501(c) #
501C#
Enter the edited 2 digit code from the lower right corner of the entity portion.
(15)
Box H Checkbox
H RTMAR
Enter the edited code from the right margin of Line 1.
(16)
In Care of Name Line
C/O NAME
Enter the in care of name, if shown.
Note:¶
Downstream processing generates a (%) sign.
(17)
Foreign Address
FGN ADD
Enter the foreign street address, if shown. See IRM 3.24.38 for additional instructions.
(18)
Street Address
ADDR
Enter the street address from the address line.
See IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information even if prompted. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(19)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(20)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.)
(21)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
Form 990-EZ - Section 02 (5800, Edit Sheet) (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and return is a remittance, press
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is NOT underlined, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800.
For special instructions, see IRM 3.24.38.
(7)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, For special instructions, see IRM 3.24.38.
Form 990-EZ - Section 03 (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY EXCEPT FOR E–(2).
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
If the ERS Action Code is in the "600" series, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Total Contributions, Gifts, Grants
LN1 $
Enter the amount from Part I, Line 1.
(4)
Program Service Revenue
LN2 $
Enter the amount from Part I, Line 2.
(5)
Membership Dues and Assessments
LN3 $
Enter the amount from Part I, Line 3.
(6)
Investment Income
LN4 $
Enter the amount from Part I, Line 4.
(7)
Gross Amount from Sale of Assets
L5A $
Enter the amount from Part I, Line 5a.
(8)
Less Cost or Other Basis
L5B $
Enter the amount from Part I, Line 5b.
(9)
Gain/Loss Other
L5C $
Enter the amount from Part I, Line 5c.
(10)
Gross Income from Gaming
L6A $
Enter the amount from Part I, Line 6a.
(11)
Gross Income from Fundraising
L6B $
Enter the amount from Part I, Line 6b.
(12)
Less Direct Expenses
L6C $
Enter the amount from Part I, Line 6c.
(13)
Net Income/Loss
L6D $
Enter the amount from Part I, Line 6d.
(14)
Gross Sales Less Returns and Allowances
L7A $
Enter the amount from Part I, Line 7a.
(15)
Less Cost of Goods Sold
L7B $
Enter the amount from Part I, Line 7b.
(16)
Gross Profit/Loss
L7C $
Enter the amount from Part I, Line 7c.
(17)
Other Revenue
LN8 $
Enter the amount from Part I, Line 8.
(18)
Total Revenue
LN9 $
Enter the amount from Part I, Line 9.
(19)
Grants & Other Similar Amounts
L10 $
Enter the amount from Part I, Line 10.
(20)
Benefits Paid to Members
L11 $
Enter the amount from Part I, Line 11.
(21)
Salaries & Other Compensation
L12 $
Enter the amount from Part I, Line 12.
(22)
Total Expenses
L17 $
Enter the amount from Part I, Line 17.
(23)
Excess (Deficit) for the Year
L18 $
Enter the amount from Part I, Line 18.
(24)
Other Changes in Net Assets
L20 $
Enter the amount from Part I, Line 20.
(25)
Net Assets at (EOY)
L21 $
Enter the amount from Part I, Line 21.
Form 990-EZ - Section 05 (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Assets (BOY)
25A $
Enter the amount from Part II, Line 25, Column (A).
(3)
Total Assets (EOY)
25B $
Enter the amount from Part II, Line 25, Column (B).
Form 990-EZ - Section 06 (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Liabilities - BOY
26A $
Enter the amount from Part II, Line 26, Column (A).
(3)
Total Liabilities - EOY
26B $
Enter the amount from Part II, Line 26, Column (B).
(4)
Net Assets - BOY
27A $
Enter the amount from Part II, Line 27, Column (A).
(5)
Net Assets - EOY
27B $
Enter the amount from Part II, Line 27, Column (B).
Form 990-EZ - Section 07 (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
IRI Codes
PG2TOP
Enter the edited digits from the top margin of Page 2.
(3)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
(4)
Did you Engage in any Activity?
33
Enter a yes or no from the yes/no box from Part V, Line 33.
(5)
Were any Changes Made?
34
Enter a yes or no from the yes/no box from Part V, Line 34.
(6)
Did you have Unrelated Business?
35A
Enter a yes or no from the yes/no box from Part V, Line 35a.
(7)
If Yes, Did you File 990–T?
35B
Enter a yes or no from the yes/no box from Part V, Line 35b.
(8)
Was organization 501(c)(4), (c)(5) or (c)(6)
35C
ENTER
Enter a yes or no from the yes/no box from Part V, Line 35c.
(9)
Was there a Liquidation?
36
Enter a yes or no from the yes/no box from Part V, Line 36.
(10)
Amount of Political Expenditures
37A $
Enter the amount from Part V, Line 37a.
(11)
Did You File 1120–POL?
37B
Enter a yes or no from the yes/no box from Part V, Line 37b.
(12)
Borrow Money From or Make Loans
38A
Enter a yes or no from the yes/no box from Part V, Line 38a.
(13)
Enter Amount Involved
38B $
Enter the amount from Part V, Line 38b.
(14)
Section 501(c)(7) Initiation Fees
39A $
Enter the amount from Part V, Line 39a.
(15)
Gross Receipts Amount
39B $
Enter the amount from Part V, Line 39b.
(16)
501(c)(3) and 501(c)(4)
40B
Enter the yes or no from the yes/no box from Part V, Line 40b.
(17)
Party to a Prohibited Tax Shelter
40E
Enter a yes or no from the yes/no box from Part V, Line 40e.
(18)
Did you have Foreign Bank Accounts?
42B
Enter a yes or no from the yes/no box from Part V, Line 42b.
(19)
Did you have a Foreign Office?
42C
Enter a yes or no from the yes/no box from Part V, Line 42c.
(20)
Section 4947(a)(1) Trusts Filing 990EZ?
43
Enter the code edited to the right of Part V, Line 43.
(21)
Maintain Any Donor Advised Funds
44A
Enter a yes or no from the yes/no box from Part V, Line 44a.
(22)
Operate One or More Hospital Facilities
44B
Enter a yes or no from the yes/no box from Part V, Line 44b.
(23)
Receive Payments for Indoor Tanning
44C
Enter a yes or no from the yes/no box from Part V, Line 44c.
(24)
Filed Form 720 to Report Payments
44D
Enter a yes or no from the yes/no box from Part V, Line 44d.
(25)
Controlled Entity Within 512(b)(13)
45A
Enter a yes or no from the yes/no box from Part V, Line 45a.
(26)
Received any payment from or engaged in transaction
45B
ENTER
Enter a yes or no from the yes/no box from Part V, Line 45b
(27)
Engage in Direct/Indirect Political Activities
46
Enter a yes or no from the yes/no box from Part V, Line 46.
(28)
Engage in Lobbying Activities
47
Enter a yes or no from the yes/no box from Part VI, Line 47.
(29)
Operating a School
48
Enter a yes or no from the yes/no box from Part VI, Line 48.
(30)
Make Any Transfers to an Exempt
49A
Enter a yes or no from the yes/no box from Part VI, Line 49a.
(31)
Section 527 Organization
49B
Enter a yes or no from the yes/no box from Part VI, Line 49b.
Form 990-EZ - Section 08 (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
Preparation Code
PREP
Enter the edited digit from the right margin of the return next to the PTIN.
(3)
Preparer's PTIN
PTIN
Enter the Preparer's PTIN.
(4)
Preparer's EIN
PEIN
Enter the Preparer's EIN.
(5)
Preparer Telephone #
TEL#
Enter the Preparer's phone number.
Form 990-EZ - Section 11, Schedule A, (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Type of Organization
L11
Enter one of the following from Line 12:
1 = Type I
2 = Type II
3= Type III- Functionally integrated
4 = Type III Non-functionally integrated Blank -
(4)
Type I, II or III Supporting Organization
L11E
Enter a “1” if the box is checked on Schedule A, Part I, Line 12e.
(5)
Number of Supported Organizations
11F
Enter the amount from Line 12f.
(6)
EIN A
12G(II)A
Enter the EIN in Part I, Line 12g, Row A, Column (ii).
(7)
Type of Org A
12G(III)A
Enter the type of organization in Part I, Line 12g, Row A, Column (iii). If more than one digit, pick up the first digit only.
(8)
Listed in Governing Doc A
12G(IV)A
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row A, Column (iv).
(9)
Amount of Support A
12G(V)A $
Enter the amount on Part I, Line 12g, Row A, Column (v).
(10)
EIN B
12G(II)B
Enter the EIN in Part I, Line 12g, Row B, Column (ii).
(11)
Type of Org B
12G(III)B
Enter the type of organization in Part I, Line 12g, Row B, Column (iii). If more than one digit, pick up the first digit only.
(12)
Listed in Governing Doc B
12G(IV)B
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row B, Column (iv).
(13)
Amount of Support B
12G(V)B $
Enter the amount Part I, Line 12g, Row B, Column (v).
(14)
EIN C
12G(II)C
Enter the EIN in Part I, Line 12g, Row C, Column (ii).
(15)
Type of Org C
12G(III)C
Enter the type of organization in Part I, Line 12g, Row C, Column (iii). If more than one digit, pick up the first digit only.
(16)
Listed in Governing Doc C
12G(IV)C
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row C, Column (iv).
(17)
Amount of Support C
12G(V)C $
Enter the amount on Part I, Line 12g, Row C, Column (v).
(18)
EIN D
12G(II)D
Enter the EIN in Part I, Line 12g, Row D, Column (ii).
(19)
Type of Org D
12G(III)D
Enter the type of organization in Part I, Line 12g, Row D, Column (iii). If more than one digit, pick up the first digit only.
(20)
Listed in Governing Doc D
12G(IV)D
Enter 1 for yes and 2 for no from check box in Part I, Line 12g, Row D, Column (iv).
(21)
Amount of Support D
12G(V)D $
Enter the amount on Part I, Line 12g, Row D, Column (v).
(22)
EIN E
12G(II)E
Enter the EIN in Part I, Line 12g, Row E, Column (ii).
(23)
Type of Org E
12G(III)E
Enter the type of organization in Part I, Line 12g, Row E, Column (iii). If more than one digit, pick up the first digit only.
(24)
Listed in Governing Doc E
12G(IV)E
Enter 1 for yes and 2 for no from check box in Part I, Line 12g, Row E, Column (iv).
(25)
Amount of Support E
12G(V)E $
Enter the amount on Part I, Line 12g, Row E, Column (v).
(26)
Filling Field
N/A
Generates blank on output.
(27)
Total Number of Organizations
12G(I)TOT
Enter the number from Schedule A, Part I, Line 12h, Column (i), Total Line.
(28)
Total Amount of Support
G(V) TOT $
Enter the amount on Part I, Line 12g, Total, Column (v).
(29)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(30)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(31)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(32)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(33)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(34)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(35)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(36)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(37)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(38)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(39)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(40)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(41)
First 5 Years Checkbox
13CKBX
Enter a 1 if the box on Schedule A, Part II, Line 13 is checked.
(42)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter a 1 if the box on Schedule A, Part II, Line 16a is checked.
(43)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter a 1 if the box on Schedule A, Part II, Line 16b is checked.
(44)
10% Facts & Circumstances Current
17ACKBX
Enter a 1 if the box on Schedule A, Part II, Line 17a is checked.
(45)
10% Facts & Circumstances Prior
17BCKBX
Enter a 1 if the box on Schedule A, Part II, Line 17b is checked.
(46)
Private Foundation Checkbox
18CKBX
Enter a 1 if the box on Schedule A, Part II, Line 18 is checked.
Form 990-EZ - Section 12, Schedule A (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter a 1 if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter a 1 if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter a 1 if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter a 1 if the box on Schedule A, Part III, Line 20 is checked.
(23)
Part IV Section A Data Present Indicator
PTIVA
Enter a 1 if data is present in Part IV, Section A.
(24)
Part IV Section B Data Present Indicator
PTIVB
Enter a 1 if data is present in Part IV, Section B.
(25)
Part IV Section C Data Present Indicator
PTIVC
Enter a 1 if data is present in Part IV, Section C.
(26)
Part IV Section D Data Present Indicator
PTIVD
Enter a 1 if data is present in Part IV, Section D.
(27)
Part IV Section E Data Present Indicator
PTIVE
Enter a 1 if data is present in Part IV, Section E.
(28)
Filling Field
N/A
N/A
Generates a blank field on output.
(29)
Excess Distributions C
PTVE3C$
Enter the amount from Part V, Section E, Line 3c.
(30)
Excess Distributions D
PTVE3D$
Enter the amount from Part V, Section E, Line 3d.
(31)
Excess Distributions E
PTVE3E$
Enter the amount from Part V, Section E, Line 3e.
(32)
Excess Distributions Breakdown B
PTVE8B$
Enter the amount from Part V, Section E, Line 8b.
(33)
Excess Distributions Breakdown C
PTVE8C$
Enter the amount from Part V, Section E, Line 8c.
(34)
Excess Distributions Breakdown D
PTVE8D$
Enter the amount from Part V, Section E, Line 8d.
(35)
Excess Distributions Breakdown E
PTVE8E$
Enter the amount from Part V, Section E, Line 8e.
Form 990-EZ - Section 13, Schedules C & L (2018 and Subsequent)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHC L2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Excess Benefit Transactions
SCHL1 RTMAR
Enter the edited digit from the right margin of Schedule L, Part I.
(4)
Approved by Board or Committee
PT2 RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
Form 990-EZ - Section 01 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section 01 always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generates the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4.
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
See standard rules in IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter Y or N as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under title of form.
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
(10)
Type of Organization
BOXGRT
Enter the edited code from right margin of box F. If the edit sheet isn't present, enter the Type of Organization from the right margin of Lines C, D or E.
(11)
Computer Condition Codes
CCC
Enter the edited characters from the dotted portion of Lines 1–3. If a Condition Code is illegible, enter a # in its place.
(12)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM 3.24.38 for special instructions.
If Type of Organization is a "9" , and the "9" is underlined, don't end the document. Continue transcribing the return.
If the Type of Organization is a "9" and the "9" is NOT underlined, press
If a "G" Condition Code is present and the return is a non-remittance, end the document after this element.
(13)
Box J 501(c) #
501C#
Enter the edited 2 digit code from the lower right corner of the entity portion.
(14)
Box H Checkbox
H RTMAR
Enter the edited code from the right margin of Line 1.
(15)
In Care of Name Line
C/O NAME
Enter the in care of name, if shown.
Note:¶
Downstream processing generates a (%) sign.
(16)
Foreign Address
FGN ADD
Enter the foreign street address, if shown. See IRM 3.24.38 for additional instructions.
(17)
Street Address
ADDR
Enter the street address from the address line.
See IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information even if prompted. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(18)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(19)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.).
(20)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
Form 990-EZ - Section 02 (5800, Edit Sheet) (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and return is a remittance, press
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is NOT underlined, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800. (a) For special instructions, see IRM 3.24.38.
(7)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990-EZ - Section 03 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY EXCEPT FOR E–(2).
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
If the ERS Action Code is in the "600" series, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Total Contributions, Gifts, Grants
LN1 $
Enter the amount from Part I, Line 1.
(4)
Program Service Revenue
LN2 $
Enter the amount from Part I, Line 2.
(5)
Membership Dues and Assessments
LN3 $
Enter the amount from Part I, Line 3.
(6)
Investment Income
LN4 $
Enter the amount from Part I, Line 4.
(7)
Gross Amount from Sale of Assets
L5A $
Enter the amount from Part I, Line 5a.
(8)
Less Cost or Other Basis
L5B $
Enter the amount from Part I, Line 5b.
(9)
Gain/Loss Other
L5C $
Enter the amount from Part I, Line 5c.
(10)
Gross Income from Gaming
L6A $
Enter the amount from Part I, Line 6a.
(11)
Gross Income from Fundraising
L6B $
Enter the amount from Part I, Line 6b.
(12)
Less Direct Expenses
L6C $
Enter the amount from Part I, Line 6c.
(13)
Net Income/Loss
L6D $
Enter the amount from Part I, Line 6d.
(14)
Gross Sales Less Returns and Allowances
L7A $
Enter the amount from Part I, Line 7a.
(15)
Less Cost of Goods Sold
L7B $
Enter the amount from Part I, Line 7b.
(16)
Gross Profit/Loss
L7C $
Enter the amount from Part I, Line 7c.
(17)
Other Revenue
LN8 $
Enter the amount from Part I, Line 8.
(18)
Total Revenue
LN9 $
Enter the amount from Part I, Line 9.
(19)
Grants & Other Similar Amounts
L10 $
Enter the amount from Part I, Line 10.
(20)
Benefits Paid to Members
L11 $
Enter the amount from Part I, Line 11.
(21)
Salaries & Other Compensation
L12 $
Enter the amount from Part I, Line 12.
(22)
Total Expenses
L17 $
Enter the amount from Part I, Line 17.
(23)
Excess (Deficit) for the Year
L18 $
Enter the amount from Part I, Line 18.
(24)
Other Changes in Net Assets
L20 $
Enter the amount from Part I, Line 20.
(25)
Net Assets at (EOY)
L21 $
Enter the amount from Part I, Line 21.
Form 990-EZ - Section 05 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Assets (BOY)
25A $
Enter the amount from Part II, Line 25, Column (A).
(3)
Total Assets (EOY)
25B $
Enter the amount from Part II, Line 25, Column (B).
Form 990-EZ - Section 06 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Liabilities - BOY
26A $
Enter the amount from Part II, Line 26, Column (A).
(3)
Total Liabilities - EOY
26B $
Enter the amount from Part II, Line 26, Column (B).
(4)
Net Assets - BOY
27A $
Enter the amount from Part II, Line 27, Column (A).
(5)
Net Assets - EOY
27B $
Enter the amount from Part II, Line 27, Column (B).
Form 990-EZ - Section 07 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
IRI Codes
PG2TOP
Enter the edited digits from the top margin of Page 2.
(3)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
(4)
Did you Engage in any Activity?
33
Enter a yes or no from the yes/no box from Part V, Line 33.
(5)
Were any Changes Made?
34
Enter a yes or no from the yes/no box from Part V, Line 34.
(6)
Did you have Unrelated Business?
35A
Enter a yes or no from the yes/no box from Part V, Line 35a.
(7)
If Yes, Did you File 990–T?
35B
Enter a yes or no from the yes/no box from Part V, Line 35b.
(8)
Was organization 501(c)(4), (c)(5) or (c)(6)
35C
ENTER
Enter a yes or no from the yes/no box from Part V, Line 35c.
(9)
Was there a Liquidation?
36
Enter a yes or no from the yes/no box from Part V, Line 36.
(10)
Amount of Political Expenditures
37A $
Enter the amount from Part V, Line 37a.
(11)
Did You File 1120–POL?
37B
Enter a yes or no from the yes/no box from Part V, Line 37b.
(12)
Borrow Money From or Make Loans
38A
Enter a yes or no from the yes/no box from Part V, Line 38a.
(13)
Enter Amount Involved
38B $
Enter the amount from Part V, Line 38b.
(14)
Section 501(c)(7) Initiation Fees
39A $
Enter the amount from Part V, Line 39a.
(15)
Gross Receipts Amount
39B $
Enter the amount from Part V, Line 39b.
(16)
501(c)(3) and 501(c)(4)
40B
Enter the yes or no from the yes/no box from Part V, Line 40b.
(17)
Party to a Prohibited Tax Shelter
40E
Enter a yes or no from the yes/no box from Part V, Line 40e.
(18)
Did you have Foreign Bank Accounts?
42B
Enter a yes or no from the yes/no box from Part V, Line 42b.
(19)
Did you have a Foreign Office?
42C
Enter a yes or no from the yes/no box from Part V, Line 42c.
(20)
Section 4947(a)(1) Trusts Filing 990EZ?
43
Enter the code edited to the right of Part V, Line 43.
(21)
Maintain Any Donor Advised Funds
44A
Enter a yes or no from the yes/no box from Part V, Line 44a.
(22)
Operate One or More Hospital Facilities
44B
Enter a yes or no from the yes/no box from Part V, Line 44b.
(23)
Receive Payments for Indoor Tanning
44C
Enter a yes or no from the yes/no box from Part V, Line 44c.
(24)
Filed Form 720 to Report Payments
44D
Enter a yes or no from the yes/no box from Part V, Line 44d.
(25)
Controlled Entity Within 512(b)(13)
45A
Enter a yes or no from the yes/no box from Part V, Line 45a.
(26)
Received any payment from or engaged in transaction
45B
ENTER
Enter a yes or no from the yes/no box from Part V, Line 45b
(27)
Engage in Direct/Indirect Political Activities
46
Enter a yes or no from the yes/no box from Part V, Line 46.
(28)
Engage in Lobbying Activities
47
Enter a yes or no from the yes/no box from Part VI, Line 47.
(29)
Operating a School
48
Enter a yes or no from the yes/no box from Part VI, Line 48.
(30)
Make Any Transfers to an Exempt
49A
Enter a yes or no from the yes/no box from Part VI, Line 49a.
(31)
Section 527 Organization
49B
Enter a yes or no from the yes/no box from Part VI, Line 49b.
Form 990-EZ - Section 08 (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
Preparation Code
PREP
Enter the edited digits from the right margin of the return next to the PTIN.
(3)
Preparer's PTIN
PTIN
Enter the Preparer's PTIN.
(4)
Preparer's EIN
PEIN
Enter the Preparer's EIN.
(5)
Preparer Telephone #
TEL#
Enter the Preparer's phone number.
Form 990-EZ - Section 11, Schedule A, (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Type of Organization
L11
Enter the following:
= Type I
= Type II
Type III- Functionally integrated
= Type III Non-functionally integrated Blank -
(4)
Type I, II or III Supporting Organization
L11E
Enter a “1” if the box is checked on Schedule A, Part I, Line 11e.
(5)
Number of Supported Organizations
11F
Enter the amount from Line 11f.
(6)
EIN A
12G(II)A
Enter the EIN in Part I, Line 12g, Row A, Column (ii).
(7)
Type of Org A
12G(III)A
Enter the type of organization in Part I, Line 12g, Row A, Column (iii). If more than one digit, pick up the first digit only.
(8)
Listed in Governing Doc A
12G(IV)A
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row A, Column (iv).
(9)
Amount of Support A
12G(V)A $
Enter the amount on Part I, Line 12g, Row A, Column (v).
(10)
EIN B
12G(II)B
Enter the EIN in Part I, Line 12g, Row B, Column (ii).
(11)
Type of Org B
12G(III)B
Enter the type of organization in Part I, Line 12g, Row B, Column (iii). If more than one digit, pick up the first digit only.
(12)
Listed in Governing Doc B
12G(IV)B
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row B, Column (iv).
(13)
Amount of Support B
12G(V)B $
Enter the amount Part I, Line 12g, Row B, Column (v).
(14)
EIN C
12G(II)C
Enter the EIN in Part I, Line 12g, Row C, Column (ii).
(15)
Type of Org C
12G(III)C
Enter the type of organization in Part I, Line 12g, Row C, Column (iii). If more than one digit, pick up the first digit only.
(16)
Listed in Governing Doc C
12G(IV)C
Enter 1 for yes and 2 for no from checkbox in Part I, Line 12g, Row C, Column (iv).
(17)
Amount of Support C
12G(V)C $
Enter the amount on Part I, Line 12g, Row C, Column (v).
(18)
EIN D
12G(II)D
Enter the EIN in Part I, Line 12g, Row D, Column (ii).
(19)
Type of Org D
12G(III)D
Enter the type of organization in Part I, Line 12g, Row D, Column (iii). If more than one digit, pick up the first digit only.
(20)
Listed in Governing Doc D
12G(IV)D
Enter 1 for yes and 2 for no from check box in Part I, Line 12g, Row D, Column (iv).
(21)
Amount of Support D
12G(V)D $
Enter the amount on Part I, Line 12g, Row D, Column (v).
(22)
EIN E
12G(II)E
Enter the EIN in Part I, Line 12g, Row E, Column (ii).
(23)
Type of Org E
12G(III)E
Enter the type of organization in Part I, Line 12g, Row E, Column (iii). If more than one digit, pick up the first digit only.
(24)
Listed in Governing Doc E
12G(IV)E
Enter 1 for yes and 2 for no from check box in Part I, Line 12g, Row E, Column (iv).
(25)
Amount of Support E
12G(V)E $
Enter the amount on Part I, Line 12g, Row E, Column (v).
(26)
Filling Field
N/A
N/A
Generates blank on output.
(27)
Total Number of Organizations
12G(I)TOT
Enter the number from Schedule A, Part I, Line 12h, Column (i), Total Line.
(28)
Total Amount of Support
GVTOT
Enter the amount on Part I, Line 12g, Total, Column (v).
(29)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(30)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(31)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(32)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(33)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(34)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(35)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(36)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(37)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(38)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(39)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(40)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(41)
First 5 Years Checkbox
13CKBX
Enter 1 if the box on Schedule A, Part II, Line 13 is checked.
(42)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter 1 if the box on Schedule A, Part II, Line 16a is checked.
(43)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter 1 if the box on Schedule A, Part II, Line 16b is checked.
(44)
10% Facts & Circumstances Current
17ACKBX
Enter 1 if the box on Schedule A, Part II, Line 17a is checked.
(45)
10% Facts & Circumstances Prior
17BCKBX
Enter 1 if the box on Schedule A, Part II, Line 17b is checked.
(46)
Private Foundation Checkbox
18CKBX
Enter 1 if the box on Schedule A, Part II, Line 18 is checked.
Form 990-EZ - Section 12, Schedule A (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter 1 if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter 1 if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter 1 if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter 1 if the box on Schedule A, Part III, Line 20 is checked.
(23)
Part IV Section A Data Present Indicator
PTIVA
Enter 1 if data is present in Part IV, Section A.
(24)
Part IV Section B Data Present Indicator
PTIVB
Enter 1 if data is present in Part IV, Section B.
(25)
Part IV Section C Data Present Indicator
PTIVC
Enter 1 if data is present in Part IV, Section C.
(26)
Part IV Section D Data Present Indicator
PTIVD
Enter 1 if data is present in Part IV, Section D.
(27)
Part IV Section E Data Present Indicator
PTIVE
Enter 1 if data is present in Part IV, Section E.
(28)
Filling Field
N/A
N/A
Generates a blank field on output.
(29)
Excess Distributions C
PTVE3C$
Enter the amount from Part V, Section E, Line 3c.
(30)
Excess Distributions D
PTVE3D$
Enter the amount from Part V, Section E, Line 3d.
(31)
Excess Distributions E
PTVE3E$
Enter the amount from Part V, Section E, Line 3e.
(32)
Excess Distributions Breakdown B
PTVE8B$
Enter the amount from Part V, Section E, Line 8b.
(33)
Excess Distributions Breakdown C
PTVE8C$
Enter the amount from Part V, Section E, Line 8c.
(34)
Excess Distributions Breakdown D
PTVE8D$
Enter the amount from Part V, Section E, Line 8d.
(35)
Excess Distributions Breakdown E
PTVE8E$
Enter the amount from Part V, Section E, Line 8e.
Form 990-EZ - Section 13, Schedules C & L (2016 and 2017)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHC L2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Excess Benefit Transactions
SCHL1 RTMAR
Enter the edited digit from the right margin of Schedule L, Part I.
(4)
Approved by Board or Committee
PT2 RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
Form 990-EZ - Section 01 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generates the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4.
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
See standard rules in IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM IRM 3.24.38 for special instructions.
(10)
Type of Organization
BOXGRT
Enter the edited code from right margin of box F. If the edit sheet isn't present, enter the Type of Organization from the right margin of Lines C, D or E.
(11)
Computer Condition Codes
CCC
Enter the edited characters from the dotted portion of Lines 1–3. If a Condition Code is illegible, enter a "#" in its place.
(12)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM IRM 3.24.38 for special instructions.
If Type of Organization is a "9" , and the "9" is underlined, don't end the document. Continue transcribing the return.
If the Type of Organization is a 9 and the 9 is NOT underlined, press
If a "G" Condition Code is present and the return is a non-remittance, end the document after this element.
(13)
Box J 501(c) #
501C#
Enter the edited 2 digit code from the lower right corner of the entity portion.
(14)
Box H Checkbox
H RTMAR
Enter the edited code from the right margin of Line 1.
(15)
In Care of Name Line
C/O NAME
Enter the in care of name, if shown.
Note:¶
Downstream processing generates a (%) sign.
(16)
Foreign Address
FGN ADD
Enter the foreign street address, if shown. See IRM 3.24.38 for additional instructions.
(17)
Street Address
ADDR
Enter the street address from the address line.
See IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information even if prompted. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(18)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(19)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.).
(20)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
Form 990-EZ - Section 02, Form 5800 Edit - Sheet (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a "non-remittance" , end the document after this element.
If the ERS Action Code is in the "600" series and the return is a "remittance" , press
If a "G" Condition Code is present and return is a "remittance," press
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is NOT underlined, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800.
For special instructions, see IRM IRM 3.24.38.
(7)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990-EZ - Section 03 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY EXCEPT FOR E–(2).
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
If the ERS Action Code is in the "600" series, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Total Contributions, Gifts, Grants
LN1 $
Enter the amount from Part I, Line 1.
(4)
Program Service Revenue
LN2 $
Enter the amount from Part I, Line 2.
(5)
Membership Dues and Assessments
LN3 $
Enter the amount from Part I, Line 3.
(6)
Investment Income
LN4 $
Enter the amount from Part I, Line 4.
(7)
Gross Amount from Sale of Assets
L5A $
Enter the amount from Part I, Line 5a.
(8)
Less Cost or Other Basis
L5B $
Enter the amount from Part I, Line 5b.
(9)
Gain/Loss Other
L5C $
Enter the amount from Part I, Line 5c.
(10)
Gross Income from Gaming
L6A $
Enter the amount from Part I, Line 6a.
(11)
Gross Income from Fundraising
L6B $
Enter the amount from Part I, Line 6b.
(12)
Less Direct Expenses
L6C $
Enter the amount from Part I, Line 6c.
(13)
Net Income/Loss
L6D $
Enter the amount from Part I, Line 6d.
(14)
Gross Sales Less Returns and Allowances
L7A $
Enter the amount from Part I, Line 7a.
(15)
Less Cost of Goods Sold
L7B $
Enter the amount from Part I, Line 7b.
(16)
Gross Profit/Loss
L7C $
Enter the amount from Part I, Line 7c.
(17)
Other Revenue
LN8 $
Enter the amount from Part I, Line 8.
(18)
Total Revenue
LN9 $
Enter the amount from Part I, Line 9.
(19)
Grants & Other Similar Amounts
L10 $
Enter the amount from Part I, Line 10.
(20)
Benefits Paid to Members
L11 $
Enter the amount from Part I, Line 11.
(21)
Salaries & Other Compensation
L12 $
Enter the amount from Part I, Line 12.
(22)
Total Expenses
L17 $
Enter the amount from Part I, Line 17.
(23)
Excess (Deficit) for the Year
L18 $
Enter the amount from Part I, Line 18.
(24)
Other Changes in Net Assets
L20 $
Enter the amount from Part I, Line 20.
(25)
Net Assets at (EOY)
L21 $
Enter the amount from Part I, Line 21.
Form 990-EZ - Section 05 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Assets (BOY)
25A $
Enter the amount from Part II, Line 25, Column (A).
(3)
Total Assets (EOY)
25B $
Enter the amount from Part II, Line 25, Column (B).
Form 990-EZ - Section 06 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Liabilities - BOY
26A $
Enter the amount from Part II, Line 26, Column (A).
(3)
Total Liabilities - EOY
26B $
Enter the amount from Part II, Line 26, Column (B).
(4)
Net Assets - BOY
27A $
Enter the amount from Part II, Line 27, Column (A).
(5)
Net Assets - EOY
27B $
Enter the amount from Part II, Line 27, Column (B).
Form 990-EZ - Section 07 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
IRI Codes
PG2TOP
Enter the edited digits from the top margin of Page 2.
(3)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
(4)
Did you Engage in any Activity?
33
Enter a yes or no from the yes/no box from Part V, Line 33.
(5)
Were any Changes Made?
34
Enter a yes or no from the yes/no box from Part V, Line 34.
(6)
Did you have Unrelated Business?
35A
Enter a yes or no from the yes/no box from Part V, Line 35a.
(7)
If Yes, Did you File 990–T?
35B
Enter a yes or no from the yes/no box from Part V, Line 35b.
(8)
Was organization 501(c)(4), (c)(5) or (c)(6)
35C
ENTER
Enter a yes or no from the yes/no box from Part V, Line 35c.
(9)
Was there a Liquidation?
36
Enter a yes or no from the yes/no box from Part V, Line 36.
(10)
Amount of Political Expenditures
37A $
Enter the amount from Part V, Line 37a.
(11)
Did You File 1120–POL?
37B
Enter a yes or no from the yes/no box from Part V, Line 37b.
(12)
Borrow Money From or Make Loans
38A
Enter a yes or no from the yes/no box from Part V, Line 38a.
(13)
Enter Amount Involved
38B $
Enter the amount from Part V, Line 38b.
(14)
Section 501(c)(7) Initiation Fees
39A $
Enter the amount from Part V, Line 39a.
(15)
Gross Receipts Amount
39B $
Enter the amount from Part V, Line 39b.
(16)
501(c)(3) and 501(c)(4)
40B
Enter the yes or no from the yes/no box from Part V, Line 40b.
(17)
Party to a Prohibited Tax Shelter
40E
Enter a yes or no from the yes/no box from Part V, Line 40e.
(18)
Did you have Foreign Bank Accounts?
42B
Enter a yes or no from the yes/no box from Part V, Line 42b.
(19)
Did you have a Foreign Office?
42C
Enter a yes or no from the yes/no box from Part V, Line 42c.
(20)
Section 4947(a)(1) Trusts Filing 990EZ?
43
Enter the code edited to the right of Part V, Line 43.
(21)
Maintain Any Donor Advised Funds
44A
Enter a yes or no from the yes/no box from Part V, Line 44a.
(22)
Operate One or More Hospital Facilities
44B
Enter a yes or no from the yes/no box from Part V, Line 44b.
(23)
Receive Payments for Indoor Tanning
44C
Enter a yes or no from the yes/no box from Part V, Line 44c.
(24)
Filed Form 720 to Report Payments
44D
Enter a yes or no from the yes/no box from Part V, Line 44d.
(25)
Controlled Entity Within 512(b)(13)
45A
Enter a yes or no from the yes/no box from Part V, Line 45a.
(26)
Received any payment from or engaged in transaction
45B
ENTER
Enter a yes or no from the yes/no box from Part V, Line 45b
(27)
Engage in Direct/Indirect Political Activities
46
Enter a yes or no from the yes/no box from Part V, Line 46.
(28)
Engage in Lobbying Activities
47
Enter a yes or no from the yes/no box from Part VI, Line 47.
(29)
Operating a School
48
Enter a yes or no from the yes/no box from Part VI, Line 48.
(230)
Make Any Transfers to an Exempt
49A
Enter a yes or no from the yes/no box from Part VI, Line 49a.
(31)
Section 527 Organization
49B
Enter a yes or no from the yes/no box from Part VI, Line 49b.
Form 990-EZ Section 08 (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
Preparation Code
PREP
Enter the edited digits from the right margin of the return next to the PTIN.
(3)
Preparer's PTIN
PTIN
Enter the Preparer's PTIN.
(4)
Preparer's EIN
PEIN
Enter the Preparer's EIN.
(5)
Preparer Telephone #
TEL#
Enter the Preparer's phone number.
Form 990-EZ - Section 11, Schedule A (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Type of Organization
11
Enter the following:
= Type I
= Type II
= Type III- Functionally integrated
= Type III Non-functionally integrated Blank -
(4)
Type I, II or III Supporting Organization
L11E
Enter a “1” if the box is checked on Schedule A, Part I, Line 11e.
(5)
Number of Supported Organizations
11F
Enter the amount from Line 11f.
(6)
EIN A
11G(II)A
Enter the EIN in Part I, Line 11g, Row A, Column (ii).
(7)
Type of Org A
11G(III)A
Enter the type of organization in Part I, Line 11g, Row A, Column (iii). If more than one digit, pick up the first digit only.
(8)
Listed in Governing Doc A
11G(IV)A
Enter 1 for yes and 2 for no from checkbox in Part I, Line 11g, Row A, Column (iv).
(9)
Amount of Support A
11G(V)A $
Enter the amount on Part I, Line 11g, Row A, Column (v).
(10)
EIN B
11G(II)B
Enter the EIN in Part I, Line 11g, Row B, Column (ii).
(11)
Type of Org B
11G(III)B
Enter the type of organization in Part I, Line 11g, Row B, Column (iii). If more than one digit, pick up the first digit only.
(12)
Listed in Governing Doc B
11G(IV)B
Enter 1 for yes and 2 for no from checkbox in Part I, Line 11g, Row B, Column (iv).
(13)
Amount of Support B
11G(V)B $
Enter the amount Part I, Line 11g, Row B, Column (v).
(14)
EIN C
11G(II)C
Enter the EIN in Part I, Line 11g, Row C, Column (ii).
(15)
Type of Org C
11G(III)C
Enter the type of organization in Part I, Line 11g, Row C, Column (iii). If more than one digit, pick up the first digit only.
(16)
Listed in Governing Doc C
11G(IV)C
Enter 1 for yes and 2 for no from checkbox in Part I, Line 11g, Row C, Column (iv).
(17)
Amount of Support C
11G(V)C $
Enter the amount on Part I, Line 11g, Row C, Column (v).
(18)
EIN D
11G(II)D
Enter the EIN in Part I, Line 11g, Row D, Column (ii).
(19)
Type of Org D
11G(III)D
Enter the type of organization in Part I, Line 11g, Row D, Column (iii). If more than one digit, pick up the first digit only.
(20)
Listed in Governing Doc D
11G(IV)D
Enter 1 for yes and 2 for no from check box in Part I, Line 11g, Row D, Column (iv).
(21)
Amount of Support D
11G(V)D $
Enter the amount on Part I, Line 11g, Row D, Column (v).
(22)
EIN E
11G(II)E
Enter the EIN in Part I, Line 11g, Row E, Column (ii).
(23)
Type of Org E
11G(III)E
Enter the type of organization in Part I, Line 11g, Row E, Column (iii). If more than one digit, pick up the first digit only.
(24)
Listed in Governing Doc E
11G(IV)E
Enter 1 for yes and 2 for no from check box in Part I, Line 11g, Row E, Column (iv).
(25)
Amount of Support E
11G(V)E $
Enter the amount on Part I, Line 11g, Row E, Column (v).
(26)
Total Number of Organizations
11G(I)TOT
Enter the number from Schedule A, Part I, Line 11h, Column (i), Total Line.
(27)
Total
GVTOT $
Enter the amount on Part I, Line 11g, Total, Column (v).
(28)
Filling Field
N/A
N/A
Blank field generates on output.
(29)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(30)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(31)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(32)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(33)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(34)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(35)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(36)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(37)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(38)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(39)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(40)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(41)
First 5 Years Checkbox
13CKBX
Enter a "1" if the box on Schedule A, Part II, Line 13 is checked.
(42)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 16a is checked.
(43)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 16b is checked.
(44)
10% Facts & Circumstances Current
17ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 17a is checked.
(45)
10% Facts & Circumstances Prior
17BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 17b is checked.
(46)
Private Foundation Checkbox
18CKBX
Enter a "1" if the box on Schedule A, Part II, Line 18 is checked.
Form 990-EZ - Section 12, Schedule A (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter a "1" if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter a "1" if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter a "1" if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter a "1" if the box on Schedule A, Part III, Line 20 is checked.
(23)
Part IV Section A Data Present Indicator
PTIVA
Enter a 1 if data is present in Part IV, Section A.
(24)
Part IV Section B Data Present Indicator
PTIVB
Enter a 1 if data is present in Part IV, Section B.
(25)
Part IV Section C Data Present Indicator
PTIVC
Enter a 1 if data is present in Part IV, Section C.
(26)
Part IV Section D Data Present Indicator
PTIVD
Enter a 1 if data is present in Part IV, Section D.
(27)
Part IV Section E Data Present Indicator
PTIVE
Enter a 1 if data is present in Part IV, Section E.
(28)
Part V Data Present Indicator
PTV
Enter a 1 if data is present in Part V.
Form 990-EZ - Section 13, Schedules C & L (2014 and 2015)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHC L2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Excess Benefit Transactions
SCHL1 RTMAR
Enter the edited digit from the right margin of Schedule L, Part I.
(4)
Approved by Board or Committee
PT2 RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
Form 990-EZ - Section 01 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generates the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4.
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
See standard rules in IRM IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM IRM 3.24.38 for special instructions.
(10)
Type of Organization
BOXGRT
Enter the edited code from right margin of box F. If the edit sheet isn't present, enter the Type of Organization from the right margin of Lines C, D or E.
(11)
Computer Condition Codes
CCC
Enter the edited characters from the dotted portion of Lines 1–3. If a Condition Code is illegible, enter a "#" in its place.
(12)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM 3.24.38 for special instructions.
If Type of Organization is a "9" , and the ""9" is underlined" , don't end the document. Continue transcribing the return.
If the Type of Organization is a "9" and the "9" is NOT underlined, press
If a "G" Condition Code is present and the return is a non-remittance, end the document after this element.
(13)
Box J 501(c) #
501C#
Enter the edited 2 digit code from the lower right corner of the entity portion.
(14)
Box H Checkbox
H RTMAR
Enter the edited code from the right margin of Line 1.
(15)
In Care of Name Line
C/O NAME
Enter the in care of name, if shown.
Note:¶
Downstream processing generates a (%) sign.
(16)
Foreign Address
FGN ADD
Enter the foreign street address, if shown. See IRM IRM 3.24.38 for additional instructions.
(17)
Street Address
ADDR
Enter the street address from the address line.
See IRM IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information even if prompted. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(18)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(19)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.).
(20)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
Form 990-EZ - Section 02 Form 5800-Edit Sheet (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and return is a remittance, press
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is underlined, don’t end the document. Continue processing the return.
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is NOT underlined, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800.
For special instructions, see IRM IRM 3.24.38.
(7)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990-EZ - Section 03 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY EXCEPT FOR E–(2).
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
If the ERS Action Code is in the "600" series, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Total Contributions, Gifts, Grants
LN1 $
Enter the amount from Part I, Line 1.
(4)
Program Service Revenue
LN2 $
Enter the amount from Part I, Line 2.
(5)
Membership Dues and Assessments
LN3 $
Enter the amount from Part I, Line 3.
(6)
Investment Income
LN4 $
Enter the amount from Part I, Line 4.
(7)
Gross Amount from Sale of Assets
L5A $
Enter the amount from Part I, Line 5a.
(8)
Less Cost or Other Basis
L5B $
Enter the amount from Part I, Line 5b.
(9)
Gain/Loss Other
L5C $
Enter the amount from Part I, Line 5c.
(10)
Gross Income from Gaming
L6A $
Enter the amount from Part I, Line 6a.
(11)
Gross Income from Fundraising
L6B $
Enter the amount from Part I, Line 6b.
(12)
Less Direct Expenses
L6C $
Enter the amount from Part I, Line 6c.
(13)
Net Income/Loss
L6D $
Enter the amount from Part I, Line 6d.
(14)
Gross Sales Less Returns and Allowances
L7A $
Enter the amount from Part I, Line 7a.
(15)
Less Cost of Goods Sold
L7B $
Enter the amount from Part I, Line 7b.
(16)
Gross Profit/Loss
L7C $
Enter the amount from Part I, Line 7c.
(17)
Other Revenue
LN8 $
Enter the amount from Part I, Line 8.
(18)
Total Revenue
LN9 $
Enter the amount from Part I, Line 9.
(19)
Grants & Other Similar Amounts
L10 $
Enter the amount from Part I, Line 10.
(20)
Benefits Paid to Members
L11 $
Enter the amount from Part I, Line 11.
(21)
Salaries & Other Compensation
L12 $
Enter the amount from Part I, Line 12.
(22)
Total Expenses
L17 $
Enter the amount from Part I, Line 17.
(23)
Excess (Deficit) for the Year
L18 $
Enter the amount from Part I, Line 18.
(24)
Other Changes in Net Assets
L20 $
Enter the amount from Part I, Line 20.
(25)
Net Assets at (EOY)
L21 $
Enter the amount from Part I, Line 21.
Form 990-EZ - Section 05 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Assets (BOY)
25A $
Enter the amount from Part II, Line 25, Column (A).
(3)
Total Assets (EOY)
25B $
Enter the amount from Part II, Line 25, Column (B).
Form 990-EZ - Section 06 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total Liabilities - BOY
26A $
Enter the amount from Part II, Line 26, Column (A).
(3)
Total Liabilities - EOY
26B $
Enter the amount from Part II, Line 26, Column (B).
(4)
Net Assets - BOY
27A $
Enter the amount from Part II, Line 27, Column (A).
(5)
Net Assets - EOY
27B $
Enter the amount from Part II, Line 27, Column (B).
Form 990-EZ - Section 07 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
IRI Codes
PG2TOP
Enter the edited digits from the top margin of Page 2.
(3)
Schedule Indicator Codes
PG3TOP
Enter the edited codes from the top of page 3.
(4)
Did you Engage in any Activity?
33
Enter a yes or no from the yes/no box from Part V, Line 33.
(5)
Were any Changes Made?
34
Enter a yes or no from the yes/no box from Part V, Line 34.
(6)
Did you have Unrelated Business?
35A
Enter a yes or no from the yes/no box from Part V, Line 35a.
(7)
If Yes, Did you File 990–T?
35B
Enter a yes or no from the yes/no box from Part V, Line 35b.
(8)
Was organization 501(c)(4), (c)(5) or (c)(6)
35C
ENTER
Enter a yes or no from the yes/no box from Part V, Line 35c.
(9)
Was there a Liquidation?
36
Enter a yes or no from the yes/no box from Part V, Line 36.
(10)
Amount of Political Expenditures
37A $
Enter the amount from Part V, Line 37a.
(11)
Did You File 1120–POL?
37B
Enter a yes or no from the yes/no box from Part V, Line 37b.
(12)
Borrow Money From or Make Loans
38A
Enter a yes or no from the yes/no box from Part V, Line 38a.
(13)
Enter Amount Involved
38B $
Enter the amount from Part V, Line 38b.
(14)
Section 501(c)(7) Initiation Fees
39A $
Enter the amount from Part V, Line 39a.
(15)
Gross Receipts Amount
39B $
Enter the amount from Part V, Line 39b.
(16)
501(c)(3) and 501(c)(4)
40B
Enter the yes or no from the yes/no box from Part V, Line 40b.
(17)
Party to a Prohibited Tax Shelter
40E
Enter a yes or no from the yes/no box from Part V, Line 40e.
(18)
Did you have Foreign Bank Accounts?
42B
Enter a yes or no from the yes/no box from Part V, Line 42b.
(19)
Did you have a Foreign Office?
42C
Enter a yes or no from the yes/no box from Part V, Line 42c.
(20)
Section 4947(a)(1) Trusts Filing 990EZ?
43
Enter the code edited to the right of Part V, Line 43.
(21)
Maintain Any Donor Advised Funds
44A
Enter a yes or no from the yes/no box from Part V, Line 44a.
(22)
Operate One or More Hospital Facilities
44B
Enter a yes or no from the yes/no box from Part V, Line 44b.
(23)
Receive Payments for Indoor Tanning
44C
Enter a yes or no from the yes/no box from Part V, Line 44c.
(24)
Filed Form 720 to Report Payments
44D
Enter a yes or no from the yes/no box from Part V, Line 44d.
(25)
Controlled Entity Within 512(b)(13)
45A
Enter a yes or no from the yes/no box from Part V, Line 45a.
(26)
Received any payment from or engaged in transaction
45B
ENTER
Enter a yes or no from the yes/no box from Part V, Line 45b
(27)
Engage in Direct/Indirect Political Activities
46
Enter a yes or no from the yes/no box from Part V, Line 46.
(28)
Engage in Lobbying Activities
47
Enter a yes or no from the yes/no box from Part VI, Line 47.
(29)
Operating a School
48
Enter a yes or no from the yes/no box from Part VI, Line 48.
(30)
Make Any Transfers to an Exempt
49A
Enter a yes or no from the yes/no box from Part VI, Line 49a.
(31)
Section 527 Organization
49B
Enter a yes or no from the yes/no box from Part VI, Line 49b.
Form 990-EZ - Section 08 (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
Preparation Code
PREP
Enter the edited digits from the right margin of the return next to the PTIN.
(3)
Preparer's PTIN
PTIN
Enter the Preparer's PTIN.
(4)
Preparer's EIN
PEIN
Enter the Preparer's EIN.
(5)
Preparer Telephone #
TEL#
Enter the Preparer's phone number.
Form 990-EZ - Section 11, Schedule A (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY
(2)
Non-Private Foundation Code
SCHAPT1
Enter the edited code to the right margin of Part I.
(3)
Total Number of Organizations
11H(I)TOT
Enter the number from Schedule A, Part I, Line 11h, Column (i), Total Line.
(4)
Total Amount of Support
HVIITOT $
Enter the amount from Schedule A, Part I, Line 11h, Column (vii), Total Line.
(5)
Gifts / Grants / Contributions
PTII 1(F) $
Enter the amount from Schedule A, Part II, Line 1, Column (f).
(6)
Tax Revenues Levied
2(F) $
Enter the amount from Schedule A, Part II, Line 2, Column (f).
(7)
Value of Services
3(F) $
Enter the amount from Schedule A, Part II, Line 3, Column (f).
(8)
Total
4(F) $
Enter the amount from Schedule A, Part II, Line 4, Column (f).
(9)
Amounts Included on Line 1
5(F) $
Enter the amount from Schedule A, Part II, Line 5, Column (f).
(10)
Public Support
6(F) $
Enter the amount from Schedule A, Part II, Line 6, Column (f).
(11)
Amount from Line 4
7(F) $
Enter the amount from Schedule A, Part II, Line 7, Column (f).
(12)
Gross Income from Interest
8(F) $
Enter the amount from Schedule A, Part II, Line 8, Column (f).
(13)
Net Income from Unrelated Business
9(F) $
Enter the amount from Schedule A, Part II, Line 9, Column (f).
(14)
Other Income
10(F) $
Enter the amount from Schedule A, Part II, Line 10, Column (f).
(15)
Total Support
11(F) $
Enter the amount from Schedule A, Part II, Line 11, Column (f).
(16)
Receipts from Related Activities
L12 $
Enter the amount from Schedule A, Part II, Line 12.
(17)
First 5 Years Checkbox
13CKBX
Enter a "1" if the box on Schedule A, Part II, Line 13 is checked.
(18)
33 1/3% Test Current Year Checkbox
16ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 16a is checked.
(19)
33 1/3% Test Prior Year Checkbox
16BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 16b is checked.
(20)
10% Facts & Circumstances Current
17ACKBX
Enter a "1" if the box on Schedule A, Part II, Line 17a is checked.
(21)
10% Facts & Circumstances Prior
17BCKBX
Enter a "1" if the box on Schedule A, Part II, Line 17b is checked.
(22)
Private Foundation Checkbox
18CKBX
Enter a "1" if the box on Schedule A, Part II, Line 18 is checked.
Form 990-EZ - Section 12, Schedule A (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part III Gifts / Grants / Contributions
PT3L1(F) $
Enter the amount from Schedule A, Part III, Line 1, Column (f).
(3)
Gross Receipts from Admissions
2(F) $
Enter the amount from Schedule A, Part III, Line 2, Column (f).
(4)
Gross Receipts from Activities
3(F) $
Enter the amount from Schedule A, Part III, Line 3, Column (f).
(5)
Tax Revenues Levied
4(F) $
Enter the amount from Schedule A, Part III, Line 4, Column (f).
(6)
Value of Services / Facilities
5(F) $
Enter the amount from Schedule A, Part III, Line 5, Column (f).
(7)
Total 509(a)(2)
6(F) $
Enter the amount from Schedule A, Part III, Line 6, Column (f).
(8)
Received from Disqualified Persons
7A(F) $
Enter the amount from Schedule A, Part III, Line 7a, Column (f).
(9)
Received from Other than Disqualified
7B(F) $
Enter the amount from Schedule A, Part III, Line 7b, Column (f).
(10)
Total of 7a & 7b
7C(F) $
Enter the amount from Schedule A, Part III, Line 7c, Column (f).
(11)
Public Support
8(F) $
Enter the amount from Schedule A, Part III, Line 8, Column (f).
(12)
Amounts from Line 6
9(F) $
Enter the amount from Schedule A, Part III, Line 9, Column (f).
(13)
Gross Income from Interest
10A(F) $
Enter the amount from Schedule A, Part III, Line 10a, Column (f).
(14)
Unrelated Business Taxable Income
10B(F) $
Enter the amount from Schedule A, Part III, Line 10b, Column (f).
(15)
Total of 10a & 10b
10C(F) $
Enter the amount from Schedule A, Part III, Line 10c, Column (f).
(16)
Net Income / Unrelated Business Activity
11(F) $
Enter the amount from Schedule A, Part III, Line 11, Column (f).
(17)
Other Income
12(F) $
Enter the amount from Schedule A, Part III, Line 12, Column (f).
(18)
Total Support
13(F) $
Enter the amount from Schedule A, Part III, Line 13, Column (f).
(19)
First 5 Years Checkbox
14CKBX
Enter a "1" if the box on Schedule A, Part III, Line 14 is checked.
(20)
33 1/3% Test Current Year Checkbox
19ACKBX
Enter a "1" if the box on Schedule A, Part III, Line 19a is checked.
(21)
33 1/3% Test Prior Year Checkbox
19BCKBX
Enter a "1" if the box on Schedule A, Part III, Line 19b is checked.
(22)
Private Foundation Checkbox
20CKBX
Enter a "1" if the box on Schedule A, Part III, Line 20 is checked.
Form 990-EZ - Section 13, Schedules C & L (2008 - 2013)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Political Expenditures
SCHC L2 $
Enter the amount from Schedule C, Part I-A, Line 2.
(3)
Excess Benefit Transactions
SCHL1 RTMAR
Enter the edited digit from the right margin of Schedule L, Part I.
(4)
Approved by Board or Committee
PT2 RTMAR
Enter the edited digit from the right margin of Schedule L, Part II.
Form 990-EZ - Section 01 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the system generates the serial number (see IRM 3.24.38.4.1.1), verify it matches the document being entered.
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4.
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control. See IRM 3.24.12.3.4.
(5)
Employer Identification Number
EIN
Enter the EIN as shown on the preprinted label or in the EIN block.
See standard rules in IRM 3.24.38.
For the error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
(10)
Type of Organization
BOXGRT
Enter the edited code from right margin of box F. If the edit sheet isn't present, enter the Type of Organization from the right margin of Lines C, D or E.
(11)
Computer Condition Codes
CCC
Enter the edited characters from the dotted portion of Lines 1–3. If a Condition Code is illegible, enter a "#" in its place.
(12)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
See IRM 3.24.38 for special instructions.
If Type of Organization is a "9" , and the "9" is underlined, don't end the document. Continue transcribing the return.
If the Type of Organization is a "9" and the "9" is NOT underlined, press
If a "G" Condition Code is present and the return is a non-remittance, end the document after this element.
(13)
Box J 501(c)
501C#
Enter the edited 2 digit code from the lower right corner of the entity portion.
(14)
Box H Checkbox
H RTMAR
Enter the edited code from the right margin of Line 1.
(15)
In Care of Name Line
C/O NAME
Enter the in care of name, if shown.
Note:¶
Downstream processing generates a (%) sign.
(16)
Foreign Address
FGN ADD
Enter the foreign street address, if shown. See IRM 3.24.38 for additional instructions.
(17)
Street Address
ADDR
Enter the street address from the address line.
See IRM 3.24.38 for specific instructions.
If a "G" Condition Code is present, do NOT enter any of the address information even if prompted. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
(18)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(19)
State
ST
Enter the standard state abbreviation from the city/state line (see IRM IRM 3.24.38).
If a Major City Code was entered, press
If a foreign address, enter a period (.).
(20)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
Form 990-EZ - Section 02, Form 5800 - Edit Sheet (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and return is a remittance, press
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is underlined, do NOT end the document. Continue processing the return.
If the Type of Organization is a "9" from Section 01 E-10, and the "9" is NOT underlined, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800. (a) For special instructions, see IRM 3.24.38.
(7)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990-EZ - Section 03 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY EXCEPT FOR E–(2).
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
f the ERS Action Code is in the "600" series, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Total Contributions, Gifts, Grants
LN1 $
Enter the amount from Part I, Line 1.
(4)
Program Service Revenue
LN2 $
Enter the amount from Part I, Line 2.
(5)
Membership Dues and Assessments
LN3 $
Enter the amount from Part I, Line 3.
(6)
Investment Income
LN4 $
Enter the amount from Part I, Line 4.
(7)
Gross Amount from Sale of Assets
L5A $
Enter the amount from Part I, Line 5a.
(8)
Less Cost or Other Basis
L5B $
Enter the amount from Part I, Line 5b.
(9)
Gain/Loss Other
L5C $
Enter the amount from Part I, Line 5c.
(10)
Special Events/Gaming
6CKBX
Enter a "1" if the check box from Part I, Line 6 is checked.
(11)
Gross Revenue
L6A $
Enter the amount from Part I, Line 6a.
(12)
Less Direct Expenses
L6B $
Enter the amount from Part I, Line 6b.
(13)
Net Income
L6C $
Enter the amount from Part I, Line 6c.
(14)
Gross Sales Less Returns and Allowances
L7A $
Enter the amount from Part I, Line 7a.
(15)
Less Cost of Goods Sold
L7B $
Enter the amount from Part I, Line 7b.
(16)
Gross Profit/Loss
L7C $
Enter the amount from Part I, Line 7c.
(17)
Other Revenue
LN8 $
Enter the amount from Part I, Line 8.
(18)
Total Revenue
LN9 $
Enter the amount from Part I, Line 9.
(19)
Grants & Other Similar Amounts
L10 $
Enter the amount from Part I, Line 10.
(20)
Benefits Paid to Members
L11 $
Enter the amount from Part I, Line 11.
(21)
Salaries & Other Compensation
L12 $
Enter the amount from Part I, Line 12.
(22)
Total Expenses
L17 $
Enter the amount from Part I, Line 17.
(23)
Excess (Deficit) for the Year
L18 $
Enter the amount from Part I, Line 18.
(24)
Other Changes in Net Assets
L20 $
Enter the amount from Part I, Line 20.
(25)
Net Assets at (EOY)
L21 $
Enter the amount from Part I, Line 21.
Form 990-EZ - Section 05 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY EXCEPT FOR E–(2).
(2)
Total Assets (BOY)
25A $
Enter the amount from Part II, Line 25, Column (A).
(3)
Total Assets (EOY)
25B $
Enter the amount from Part II, Line 25, Column (B).
Form 990-EZ - Section 06 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
Total Liabilities (BOY)
26A $
Enter the amount from Part II, Line 26, Column (A).
(3)
Total Liabilities (EOY)
26B $
Enter the amount from Part II, Line 26, Column (B).
(4)
Net Assets (BOY)
27A $
Enter the amount from Part II, Line 27, Column (A).
(5)
Net Assets (EOY)
27B $
Enter the amount from Part II, Line 27, Column (B).
Form 990-EZ - Section 07 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
IRI Codes
PG2TOP
Enter the edited digits from the top margin of Page 2.
(3)
Did you Engage in any Activity?
33
Enter a yes or no from the yes/no box from Part V, Line 33.
(4)
Were any Changes Made?
34
Enter a yes or no from the yes/no box from Part V, Line 34.
(5)
Did you have Unrelated Business?
35A
Enter a yes or no from the yes/no box from Part V, Line 35a.
(6)
If Yes, Did you File 990–T?
35B
Enter a yes or no from the yes/no box from Part V, Line 35b.
(7)
Was there a Liquidation?
36
Enter a yes or no from the yes/no box from Line 36.
(8)
Amount of Political Expenditures
37A $
Enter the amount from Line 37a.
(9)
Did You File 1120–POL?
37B
Enter a yes or no from the yes/no box from Line 37b.
(10)
Section 501(c)(7) Initiation Fees
39A $
Enter the amount from Line 39a.
(11)
Gross Receipts Amount
39B $
Enter the amount from Line 39b.
(12)
501(c)(3) and 501(c)(4)
40B
Enter the yes or no from the yes/no box from Part V, Line 40b.
(13)
Did you have Foreign Bank Accounts?
42B
Enter a yes or no from the yes/no box from Part V, Line 42b.
(14)
Did you have a Foreign Office?
42C
Enter a yes or no from the yes/no box from Part V, Line 42c.
(15)
Section 4947(a)(1) Trusts Filing 990EZ?
43
Enter the code edited to the right of Part V, Line 43.
Form 990-EZ - Section 08 (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
Preparation Code
PREP
Enter the edited digits from the right margin of the last page of the return next to the PTIN.
(3)
Preparer's PTIN
PTIN
Enter the Preparer's PTIN.
(4)
Preparer's EIN
PEIN
Enter the Preparer's EIN.
Form 990-EZ - Section 09, Schedule A (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY
(2)
Question 1 Part III
LN1
Enter the edited digit to the right of Part III, Line 1.
If un-edited, enter a yes or no from the yes/no box from Part III, Line 1.
(3)
Legislative Activities
LN1 $
Enter the amount from Part III, Line 1, next to the $.
(4)
Was there a Sale, Exchange or Lease of Property?
L2A
Enter a yes or no from the yes/no box from Part III, Line 2a.
(5)
Did you Lend Money or Other Credit?
L2B
Enter a yes or no from the yes/no box from Part III, Line 2b.
(6)
Did you Furnish Goods, Services or Facilities?
L2C
Enter a yes or no from the yes/no box from Part III, Line 2c.
(7)
Did you make Payment Compensation?
L2D
Enter a yes or no from the yes/no box from Part III, Line 2d.
(8)
Did you Transfer Income or Assets?
L2E
Enter a yes or no from the yes/no box from Part III, Line 2e.
(9)
Do you Make Grants/Scholarships?
L3A
Enter a yes or no from the yes/no box from Part III, Line 3a.
(10)
Did you Have a Section 403(b) Annuity Plan?
L3B
Enter a yes or no from the yes/no box from Part III, Line 3b.
(11)
Did you Receive or Hold Easement - Section 170(h)?
L3C
Enter a yes or no from the yes/no box from Part III, Line 3c.
(12)
Do you Provide Credit Counseling?
L3D
Enter a yes or no from the yes/no box from Part III, Line 3d.
(13)
Did you Maintain any Donor Advised Funds?
L4A
Enter a yes or no from the yes/no box from Part III, Line 4a.
(14)
Did you Make any Taxable Distributions?
L4B
Enter a yes or no from the yes/no box from Part III, Line 4b.
(15)
Did you Make a Distribution – Section 4967?
L4C
Enter a yes or no from the yes/no box from Part III, Line 4c.
(16)
Enter the Total Number of Donor Advised Funds
L4D
Enter the number from Part III, Line 4d.
(17)
Enter the Aggregate Value of Assets
L4E $
Enter the amount from Part III, Line 4e.
(18)
Part IV Non-Private Foundation
IVRTMAR
Enter the edited code from the RIGHT margin of Part IV.
(19)
Total Amount of Support
13E $
Enter the amount from Part IV, Line 13, Column (e).
(20)
Gifts, Contributions, Grants
15E $
Enter the amount from Part IV-A, Line 15, Column (e).
(21)
Membership Fees
16E $
Enter the amount from Part IV-A, Line 16, Column (e).
(22)
Gross Receipts/Admissions
17E $
Enter the amount from Part IV-A, Line 17, Column (e).
(23)
Gross Income/Interest/Dividends
18E $
Enter the amount from Part IV-A, Line 18, Column (e).
(24)
Tax Revenues Levied
20E $
Enter the amount from Part IV-A, Line 20, Column (e).
(25)
Value of Services/Facilities Furnished
21E $
Enter the amount from Part IV-A, Line 21, Column (e).
(26)
Total Lines 15–22
23E $
Enter the amount from Part IV-A, Line 23, Column (e).
(27)
Line 23 Minus 17
24E $
Enter the amount from Part IV-A, Line 24, Column (e).
Form 990-EZ - Section 10, Schedule A (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
If a large edited X is present through Part V or Part V is blank, don't enter this section.
(2)
Do you have a racially?
V29
Enter a yes or no from the yes/no box from Part V, Line 29.
(3)
Do you include?
30
Enter a yes or no from the yes/no box from Part V, Line 30.
(4)
Have you publicized?
31
Enter a yes or no from the yes/no box from Part V, Line 31.
(5)
Records indicating?
32A
Enter a yes or no from the yes/no box from Part V, Line 32a.
(6)
Records documenting?
32B
Enter a yes or no from the yes/no box from Part V, Line 32b.
(7)
Copies of all catalogues?
32C
Enter a yes or no from the yes/no box from Part V, Line 32c.
(8)
Copies of all material?
32D
Enter a yes or no from the yes/no box from Part V, Line 32d.
(9)
Students' rights?
33A
Enter a yes or no from the yes/no box from Part V, Line 33a.
(10)
Admission Policies?
33B
Enter a yes or no from the yes/no box from Part V, Line 33b.
(11)
Employment of faculty?
33C
Enter a yes or no from the yes/no box from Part V, Line 33c.
(12)
Scholarships?
33D
Enter a yes or no from the yes/no box from Part V, Line 33d.
(13)
Educational policies?
33E
Enter a yes or no from the yes/no box from Part V, Line 33e.
(14)
Use of facilities?
33F
Enter a yes or no from the yes/no box from Part V, Line 33f.
(15)
Athletic programs?
33G
Enter a yes or no from the yes/no box from Part V, Line 33g.
(16)
Other extracurricular activities?
33H
Enter a yes or no from the yes/no box from Part V, Line 33h.
(17)
Does Organization Certify?
35
Enter a yes or no from the yes/no box from Part V, Line 35.
(18)
Signature Code
SIGN
Enter the edited code from the bottom right hand portion of Schedule A, page 5.
Form 990-EZ - Section 11, Schedule A (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY.
(2)
Total (Grass Roots) Expenditures
36B $
Enter the amount from Part VI-A, Line 36, Column (b).
(3)
Total Lobbying Expenses
37B $
Enter the amount from Part VI-A, Line 37, Column (b).
(4)
Other Exempt Purposes Expenses
39B $
Enter the amount from Part VI-A, Line 39, Column (b).
(5)
Lobbying Nontaxable Amount
41B $
Enter the amount from Part VI-A, Line 41, Column (b).
(6)
Grass Roots Nontaxable Amount
42B $
Enter the amount from Part VI-A, Line 42, Column (b).
(7)
Excess of Line 36 over Line 42
43B $
Enter the amount from Part VI-A, Line 43, Column (b).
(8)
Excess of Line 38 over Line 41
44B $
Enter the amount from Part VI-A, Line 44, Column (b).
(9)
Part VI-B, Line i, Total
VIBLNI $
Enter the amount from Part VI-B, Line i.
Form 990-EZ - Section 12, Schedule A (2007 and Prior)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash transfers?
51AI
Enter a yes or no from the yes/no box from Part VII, Line 51a(i).
(3)
Other assets?
AII
Enter a yes or no from the yes/no box from Part VII, Line 51a(ii).
(4)
Sales of assets?
51BI
Enter a yes or no from the yes/no box from Part VII, Line 51b(i).
(5)
Purchases of assets?
BII
Enter a yes or no from the yes/no box from Part VII, Line 51b(ii).
(6)
Rental?
BIII
Enter a yes or no from the yes/no box from Part VII, Line 51b(iii).
(7)
Reimbursement?
BIV
Enter a yes or no from the yes/no box from Part VII, Line 51b(iv).
(8)
Loans?
BV
Enter a yes or no from the yes/no box from Part VII, Line 51b(v).
(9)
Performance of services?
BVI
Enter a yes or no from the yes/no box from Part VII, Line 51b(vi).
(10)
Sharing?
51C
Enter a yes or no from the yes/no box from Part VII, Line 51c.
Form 990-PF - Section 01¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4
(5)
E.I. Number
EIN
Enter the E.I. Number from the preprinted label or from E.I. Number block.
See standard rules in IRM 3.24.38.
For error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
(10)
Type of Organization Code
C RTMAR
Enter the edited code from right margin of box C/D.
(11)
Foundation Code
LN H
Enter the edited digits from Line H.
(12)
Termination Code
F RTMAR
Enter the edited code from right margin of box F.
(13)
Line 2 Checkbox
LN2
Enter the code if edited from the right margin of Line 1a.
(14)
Computer Condition Codes
CCC
Enter the codes shown on the dotted portion of Lines 8–9.
If a condition code is illegible, enter a "#" in its place.
(15)
Return Processing Code
01RPC
For 2018 and subsequent tax periods enter the edited codes on Page 1, in the right margin next to line 2.
(16)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
If a "G" Condition Code is present and the return is a non-remittance, end the document after this element.
See IRM 3.24.38 for special instructions.
(17)
In Care of Name Line
C/O NAME
Enter the in care of name, if shown.
Note:¶
Downstream processing generates an (%) sign.
(18)
Foreign Address
FGN ADD
Enter the foreign street address, if shown.
See IRM 3.24.38 for additional instructions.
(19)
Street Address
ADDR
Enter the street address from the address line.
If a "G" Condition Code is present on the return, do NOT enter any of the address information even if prompted. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
See IRM 3.24.38 for specific instructions.
(20)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(21)
State
ST
Enter the standard state abbreviation from the city/state line.
If a Major City Code was entered, press
If a foreign address, enter a period (.).
See IRM 3.24.38.
(22)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
Form 990-PF - Section 02, Form 5800 - Edit Sheet¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
BOTLFMAR
Enter the edited digits from Bottom Left Margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and return is a remittance, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800, in MMDDYY format.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800.
For special instructions, see IRM 3.24.38.
(7)
Penalty and Interest Code
LN6
Enter the edited digit from Line 6, Form 5800.
(8)
Daily Delinquency Penalty
LN7
Enter the edited amount exactly as shown on Line 7, Form 5800.
Form 990-PF - Section 03¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
ENTER DOLLARS ONLY EXCEPT FOR E–(2).
(2)
Remittance
RMT
Enter the edited DOLLARS AND CENTS amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
If the ERS Action Code is in the "600" series, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Fair Market Value of Assets (EOY)
BOXI $
Enter the amount from Box I, top portion of the return.
(4)
Contributions, Gifts, Etc.
L1A $
Enter the amount from Part I, Line 1, Column (a).
(5)
Interest on Savings
L3A $
Enter the amount from Part I, Line 3, Column (a).
(6)
Dividends & Interest
L4A $
Enter the amount from Part I, Line 4, Column (a).
(7)
Gross Rents
5AA $
Enter the amount from Part I, Line 5a, Column (a).
(8)
Net Gain or Loss
L6A $
Enter the amount from Part I, Line 6a, Column (a).
(9)
Gross Sales Price on Line 6a
L6B $
Enter the amount from Part I, Line 6b.
(10)
Cost of Goods Sold
10B $
Enter the amount from Part I, Line 10b.
(11)
Gross Profit from Business
10CA $
Enter the amount from Part I, Line 10c, Column (a).
(12)
Other Income
11A $
Enter the amount from Part I, Line 11, Column (a).
(13)
Total Revenue per Book
12A $
Enter the amount from Part I, Line 12, Column (a).
(14)
Total Net Investment Income
12B $
Enter the amount from Part I, Line 12, Column (b).
(15)
Total Adjusted Net Income
12C $
Enter the amount from Part I, Line 12, Column (c).
(16)
Compensation of Officers
13A $
Enter the amount from Part I, Line 13, Column (a).
(17)
Pension Plan Employee Benefits
15A $
Enter the amount from Part I, Line 15, Column (a).
(18)
Legal Fees
16AA $
Enter the amount from Part I, Line 16a, Column (a).
(19)
Accounting Fees
16BA $
Enter the amount from Part I, Line 16b, Column (a).
(20)
Interest
17A $
Enter the amount from Part I, Line 17, Column (a).
(21)
Depreciation
19A $
Enter the amount from Part I, Line 19, Column (a).
(22)
Occupancy
20A $
Enter the amount from Part I, Line 20, Column (a).
(23)
Travel/Conferences and Meetings
21A $
Enter the amount form Part I, Line 21, Column (a).
(24)
Printing and Publications
22A $
Enter the amount from Part I, Line 22, Column (a).
(25)
Total Operating & Admin. Expenses Col. A
24A $
Enter the amount from Part I, Line 24, Column (a).
(26)
Total Operating & Admin. Expenses Col. B
24B $
Enter the amount from Part I, Line 24, Column (b).
(27)
Total Operating and Admin. Expenses Col. D
24D $
Enter the amount from Part I, Line 24, Column (d).
(28)
Contributions, Gifts, Grants Paid
25A $
Enter the amount from Part I, Line 25, Column (a).
(29)
Total Expenses Per Books
26A $
Enter the amount from Part I, Line 26, Column (a).
(30)
Total Expenses Net Investment
26B $
Enter the amount from Part I, Line 26, Column (b).
(31)
Total Expenses Adjusted Net
26C $
Enter the amount from Part I, Line 26, Column (c).
(32)
Total Expenses Disbursements
26D $
Enter the amount from Part I, Line 26, Column (d).
(33)
Excess of Revenue
27AA $
Enter the amount from Part I, Line 27a, Column (a).
(34)
Net Investment Income
27BB $
Enter the amount from Part I, Line 27b, Column (b).
(35)
Adjusted Net Income
27CC $
Enter the amount from Part I, Line 27c, Column (c).
Form 990-PF - Section 04¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
Note:¶
If the return is for a prior year, "04" will be edited to the left of the Part Number that is to be entered. The line items remains the same.
(2)
IRI Codes
PG2TOP
Enter the edited digits from the top of Page 2 or the return.
(3)
Cash Non Interest (BOY)
L1A $
Enter the amount from Part II, Line 1, Column (a).
(4)
Cash Non Interest (EOY)
L1B $
Enter the amount from Part II, Line 1, Column (b).
(5)
Accounts Receivable Less Allowances (BOY)
L3A $
Enter the amount from Part II, Line 3, Column (a).
(6)
Accounts Receivable Less Allowance (EOY)
L3B $
Enter the amount from Part II, Line 3, Column (b).
(7)
Pledges Receivable Less Allowances (BOY)
L4A $
Enter the amount from Part II, Line 4, Column (a).
(8)
Pledges Receivable Less Allowances (EOY)
L4B $
Enter the amount from Part II, Line 4, Column (b).
(9)
Grants Receivable (BOY)
L5A $
Enter the amount from Part II, Line 5, Column (a).
(10)
Grants Receivable (EOY)
L5B $
Enter the amount from Part II, Line 5, Column (b).
(11)
Receivables Due From Officers (BOY)
L6A $
Enter the amount from Part II, Line 6, column (a).
(12)
Receivables Due From Officers (EOY)
L6B $
Enter the amount from Part II, Line 6, Column (b).
(13)
Other Notes and Loans (BOY)
L7A $
Enter the amount from Part II, Line 7, Column (a).
(14)
Other Notes and Loans (EOY)
L7B $
Enter the amount from Part II, Line 7, Column (b).
(15)
Inventories for Sale (BOY)
L8A $
Enter the amount from Part II, Line 8, Column (a).
(16)
Inventories for Sale (EOY)
L8B $
Enter the amount from Part II, Line 8, Column (b).
(17)
Prepaid Expenses (BOY)
L9A $
Enter the amount from Part II, Line 9, Column (a).
(18)
Prepaid Expenses (EOY)
L9B $
Enter the amount from Part II, Line 9, Column (b).
(19)
Investments-Government (BOY)
10AA $
Enter the amount from Part II, Line 10a, Column (a).
(20)
Investments-Government (EOY)
10AB $
Enter the amount from Part II, Line 10a, Column (b).
(21)
Investment Stock (BOY)
10BA $
Enter the amount from Part II, Line 10b, Column (a).
(22)
Investment Stock (EOY)
10BB $
Enter the amount from Part II, Line 10b, Column (b).
(23)
Investment Bonds (BOY)
10CA $
Enter the amount from Part II, Line 10c, Column (a).
(24)
Investment Bonds (EOY)
10CB $
Enter the amount from Part II, Line 10c, Column (b).
(25)
Investment Mortgage Loans (BOY)
12A $
Enter the amount from Part II, Line 12, Column (a).
(26)
Investment Mortgage Loans (EOY)
12B $
Enter the amount from Part II, Line 12, Column (b).
(27)
Investment Other (BOY)
13A $
Enter the amount from Part II, Line 13, Column (a).
(28)
Investment Other (EOY)
13B $
Enter the amount from Part II, Line 13, Column (b).
(29)
Land, Buildings and Equipment (BOY)
14A $
Enter the amount from Part II, Line 14, Column (a).
(30)
Land, Buildings and Equipment (EOY)
14B $
Enter the amount from Part II, Line 14, Column (b).
(31)
Other Assets (BOY)
15A $
Enter the amount from Part II, Line 15, Column (a).
(32)
Other Assets (EOY)
15B $
Enter the amount from Part II, Line 15, Column (b).
(33)
Total Assets (EOY)
16B $
Enter the amount from Part II, Line 16, Column (b).
(34)
FMV of Assets (EOY)
16C $
Enter the amount from Part II, Line 16, Column (c).
Form 990-PF - Section 05¶
Elem
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
Note:¶
If the return is for a prior year, "05" will be edited to the left of the Part Number that is to be entered. The Line items remains the same.
(2)
Accounts Payable (BOY)
17A $
Enter the amount from Part II, Line 17, Column (a).
(3)
Accounts Payable (EOY)
17B $
Enter the amount from Part II, Line 17, Column (b).
(4)
Grants Payable (BOY)
18A $
Enter the amount from Part II, Line 18, Column (a).
(5)
Grants Payable (EOY)
18B $
Enter the amount from Part II, Line 18, Column (b).
(6)
Mortgages and Notes (EOY)
21B $
Enter the amount from Part II, Line 21, Column (b).
(7)
Other Liabilities (BOY)
22A $
Enter the amount from Part II, Line 22, Column (a).
(8)
Other Liabilities (EOY)
22B $
Enter the amount from Part II, Line 22, Column (b).
(9)
Total Liabilities (EOY)
23B $
Enter the amount from Part II, Line 23, Column (b).
(10)
Total Net Assets/Fund Balances
29B $
Enter the amount from Part II, Line 29, Column (b).
(11)
4940 Code
PG4TOP
Enter the edited code from the top center margin of page 4 of the return.
(12)
Excise Tax
LN1
Enter the amount from Part V, Line 1.
(13)
Section 511 Tax
LN2
Enter the amount from Part V, Line 2.
(14)
Subtitle A Tax
LN4
Enter the amount from Part V, Line 4.
(15)
Tax on Investment Income
LN5
Enter the amount from Part V, Line 5.
(16)
ES Credit
L6A
Enter the amount from Part V, Line 6a.
(17)
Tax Withheld at Source
L6B
Enter the amount from Part V, Line 6b.
(18)
Tax Paid from Form 8868
L6C
Enter the amount from Part V, Line 6c.
(19)
Erroneous Backup Withholding
L6D
Enter the amount from Part V, Line 6d.
(20)
ES Penalty
LN8
Enter the amount from Part V, Line 8.
(21)
Tax Due/Overpayment
L9/10
Enter the amount from Part V, Line 9 followed by pressing
If no amount on Line 9, enter the amount from Part VI, Line 10 with a MINUS (−).
If entries on both lines, enter the amount from Part VI, Line 9 followed by pressing
(22)
Credit Elect
11 CT
Enter the amount from Part V, the center portion of Line 11.
Form 990-PF - Section 06¶
Elem
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
During this tax year?
VIIA1A
Enter a yes or no from the yes/no box on Part VI-A, Line 1a.
(3)
Have you engaged in?
LN2
Enter a yes or no from the yes/no box on Part VI-A, Line 2.
(4)
Have you made any changes?
LN3
Enter a yes or no from the yes/no box on Part VI-A, Line 3.
(5)
If yes, have you?
L4B
Enter a yes or no from the yes/no box on Part VI-A, Line 4b.
(6)
Was there a liquidation?
LN5
Enter a yes or no from the yes/no box on Part VI-A, Line 5.
(7)
If you answered yes?
L8B
Enter a yes or no from the yes/no box on Part VI-A, Line 8b.
(8)
Are you claiming?
LN9
Enter a yes or no from the yes/no box on Part VI-A, Line 9.
(9)
Did any Persons Become?
L10
Enter a yes or no from the yes/no box on Part VI-A, Line 10.
(10)
Is the Foundation a Controlling Organization?
L11
Enter a yes or no from the yes/no box on Part VI-A, Line 11.
(11)
Did you Acquire Direct/Indirect Interest?
L12
Enter a yes or no from the yes/no box from Part VI-A, Line 12.
(12)
Did the Organization Comply with Public?
L13
Enter a yes or no from the yes/no box from Part VI-A, 1 Line 13.
(13)
Section 4947(a)(1) Trusts
L15
Enter a "1" if the box is checked on Part VI-A, Line 15.
(14)
Did the foundation have any interest income
L16
ENTER
Enter a yes or no from the yes/no box on Part VI-A, Line 16.
(15)
Engage in the sale?
VIIB1A1
Enter a yes or no from the yes/no box on Part VI-B, Line 1a(1).
(16)
Borrow money from?
1A2
Enter a yes or no from the yes/no box on Part VI-B, Line 1a(2).
(17)
Furnish goods?
1A3
Enter a yes or no from the yes/no box on Part VI-B, Line 1a(3).
(18)
Pay compensation?
1A4
Enter a yes or no from the yes/no box on Part VI-B, Line 1a(4).
(19)
Transfer any of?
1A5
Enter a yes or no from the yes/no box on Part VI-B, Line 1a(5).
(20)
Agree to pay money?
1A6
Enter a yes or no from the yes/no box on Part VI-B, Line 1a(6).
(21)
If you answered yes?
1B
Enter a yes or no from the yes/no box on Part VI-B, Line 1b.
(22)
Did you engage in?
1C
Enter a yes or no from the yes/no box on Part VI-B, Line 1c.
(23)
Taxes on failure to?
2A
Enter a yes or no from the yes/no box on Part VI-B, Line 2a.
(24)
If 2a is yes?
2B
Enter a yes or no from the yes/no box on Part VI-B, Line 2b.
(25)
Did you hold more?
3A
Enter a yes or no from the yes/no box on Part VI-B, Line 3a.
(26)
If yes, did you?
3B
Enter a yes or no from the yes/no box on Part VI-B, Line 3b.
(27)
Did you invest during?
4A
Enter a yes or no from the yes/no box on Part VI-B, Line 4a.
(28)
Did you make any?
4B
Enter a yes or no from the yes/no box on Part VI-B, Line 4b.
(29)
Carry on propaganda?
5A1
Enter a yes or no from the yes/no box on Part VI-B, Line 5a(1).
(30)
Influence the outcome?
5A2
Enter a yes or no from the yes/no box on Part VI-B, Line 5a(2).
(31)
Provide a grant?
5A3
Enter a yes or no from the yes/no box on Part VI-B, Line 5a(3).
(32)
Provide grant to an organization?
5A4
Enter a yes or no from the yes/no box on Part VI-B, Line 5a(4).
(33)
Provide for any?
5A5
Enter a yes or no from the yes/no box on Part VI-B, Line 5a(5).
(34)
If you answered yes?
5B
Enter a yes or no from the yes/no box on Part VI-B, Line 5b.
(35)
Did the Organization Receive any Funds?
6A
Enter a yes or no from the yes/no box on Part VI-B, Line 6a.
(36)
Did the Organization Pay any Premiums?
6B
Enter a yes or no from the yes/no box on Part VI-B, Line 6b.
(37)
Subject to Section 4960 Tax on Payments of More Than $1,000,000
8
Enter 1 for yes and 2 for no Part VI-B, Line 8.
Form 990-PF - Section 07¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
Note:¶
If the return is for a prior year, "07" will be edited to the left of the Part Number that is to be entered. The line items remains the same.
(2)
Reportable Compensation 1
PTVIII1C $
Enter the amount from Part VII Section 1, Line 1, Column (c).
(3)
Reportable Contributions to Employee Benefits Plans 1
PTVIII1D $
Enter the amount from Part VII Section 1, Line 1, Column (d).
(4)
Reportable Compensation 2
PTVIII2C $
Enter the amount from Part VII Section 1, Line 2, Column (c).
(5)
Reportable Contributions to Employee Benefits Plans 2
PTVIII2D $
Enter the amount from Part VII Section 1, Line 2, Column (d).
(6)
Reportable Compensation 3
PTVIII3C $
Enter the amount from Part VII Section 1, Line 3, Column (c).
(7)
Reportable Contributions to Employee Benefits Plans 3
PTVIII3D $
Enter the amount from Part VIII Section 1, Line 3, Column (d).
(8)
Reportable Compensation 4
PTVIII4C $
Enter the amount from Part VII Section 1, Line 4, Column (c).
(9)
Reportable Contributions to Employee Benefits Plans 4
PTVIII4D $
Enter the amount from Part VII Section 1, Line 4, Column (d).
(10)
Five Highest Paid Employees Compensation 1
PTVIII21C $
Enter the amount from Part VII Section 2, Line 1, Column (c).
(11)
Five Highest Paid Contributions to Employee Benefits Plans 1
PTVIII21D $
Enter the amount from Part VII Section 2, Line 1, Column (d).
(12)
Five Highest Paid Employees Compensation 2
PTVIII22C $
Enter the amount from Part VII Section 2, Line 2, Column (c).
(13)
Five Highest Paid Contributions to Employee Benefits Plans 2
PTVIII22D $
Enter the amount from Part VII Section 2, Line 2, Column (d).
(14)
Five Highest Paid Employees Compensation 3
PTVIII23C $
Enter the amount from Part VII Section 2, Line 3, Column (c).
(15)
Five Highest Paid Contributions to Employee Benefits Plans 3
PTVIII23D $
Enter the amount from Part VII Section 2, Line 3, Column (d).
(16)
Five Highest Paid Employees Compensation 4
PTVIII24C $
Enter the amount from Part VII Section 2, Line 4, Column (c).
(17)
Five Highest Paid Contributions to Employee Benefits Plans 4
PTVIII24D $
Enter the amount from Part VII Section 2, Line 4, Column (d).
(18)
Five Highest Paid Employees Compensation 5
PTVIII25C $
Enter the amount from Part VII Section 2, Line 5, Column (c).
(19)
Five Highest Paid Contributions to Employee Benefits Plans 5
PTVIII25D $
Enter the amount from Part VII Section 2, Line 5, Column (d).
(20)
Total
X1D $
Enter the amount from Part IX, Line 1d.
(21)
Net Value/Noncharitable-Use Assets
LN5 $
Enter the amount from Part IX, Line 5.
(22)
Minimum Investment Return
LN6 $
Enter the amount from Part IX, Line 6.
(23)
Distributable Amount
XI7 $
Enter the amount from Part X, Line 7.
(24)
Undistributed Income
XIII6F $
Enter the amount from Part XII, Line 6f.
Form 990-PF - Section 08¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
Note:¶
If the return is for a prior year, "08" edits to the left of the lines to be entered. The line items remain the same.
(2)
Adjusted Net Income Column (a)
2AA $
Enter the amount from Part XIII, Line 2a, Column (a).
(3)
Adjusted Net Income Column (b)
2AB $
Enter the amount from Part XIII, Line 2a, Column (b).
(4)
Adjusted Net Income Column (c)
2AC $
Enter the amount from Part XIII, Line 2a, Column (c).
(5)
Adjusted Net Income Column (d)
2AD $
Enter the amount from Part XIII, Line 2a, Column (d).
(6)
Adjusted Net Income Total
2AE $
Enter the amount from Part XIII, Line 2a, Column (e).
(7)
Qualifying Distribution Column (a)
2EA $
Enter the amount from Part XIII, Line 2e, Column (a).
(8)
Qualifying Distribution Column (b)
2EB $
Enter the amount from Part XIII, Line 2e, Column (b).
(9)
Qualifying Distribution Column (c)
2EC $
Enter the amount from Part XIII, Line 2e, Column (c).
(10)
Qualifying Distribution Column (d)
2ED $
Enter the amount from Part XIII, Line 2e, Column (d).
(11)
Qualifying Distribution Total
2EE $
Enter the amount from Part XIII, Line 2e, Column (e).
Form 990-PF - Section 09¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
Note:¶
If the return is for a prior year, "09" edits to the left of the lines to be entered. The line items remain the same.
(2)
Value of Assets Column (a)
3A1A $
Enter the amount from Part XIII, Line 3a(1), Column (a).
(3)
Value of Assets Column (b)
3A1B $
Enter the amount from Part XIII, Line 3a(1), Column (b).
(4)
Value of Assets Column (c)
3A1C $
Enter the amount from Part XIII, Line 3a(1), Column (c).
(5)
Value of Assets Column (d)
3A1D $
Enter the amount from Part XIII, Line 3a(1), Column (d).
(6)
Value of Assets Total
3A1E $
Enter the amount from Part XIII, Line 3a(1), Column (e).
(7)
Value of Assets Qualifying Column (a)
3A2A $
Enter the amount from Part XIII, Line 3a(2), Column (a).
(8)
Value of Assets Qualifying Column (b)
3A2B $
Enter the amount from Part XIII, Line 3a(2), Column (b).
(9)
Value of Assets Qualifying Column (c)
3A2C $
Enter the amount from Part XIII, Line 3a(2), Column (c).
(10)
Value of Assets Qualifying Column (d)
3A2D $
Enter the amount from Part XIII, Line 3a(2), Column (d).
(11)
Value of Assets Qualifying Total
3A2E $
Enter the amount from Part XIII, Line 3a(2), Column (e).
Form 990-PF - Section 10¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
Note:¶
If the return is for a prior year, "10" edits to the left of the lines to be entered. The line items remain the same.
(2)
Alternative Test Endowment, Column (a)
3BA $
Enter the amount from Part XIII, Line 3b, Column (a).
(3)
Alternative Test Endowment, Column (b)
3BB $
Enter the amount from Part XIII, Line 3b, Column (b).
(4)
Alternative Test Endowment, Column (c)
3BC $
Enter the amount from Part XIII, Line 3b, Column (c).
(5)
Alternative Test Endowment, Column (d)
3BD $
Enter the amount from Part XIII, Line 3b, Column (d).
(6)
Alternative Test Endowment, Total
3BE $
Enter the amount from Part XIII, Line 3b, Column (e).
(7)
Total Support, Column (a)
3C1A $
Enter the amount from Part XIII, Line 3c(1), Column (a).
(8)
Total Support, Column (b)
3C1B $
Enter the amount from Part XIII, Line 3c(1), Column (b).
(9)
Total Support, Column (c)
3C1C $
Enter the amount from Part XIII, Line 3c(1), Column (c).
(10)
Total Support, Column (d)
3C1D $
Enter the amount from Part XIII, Line 3c(1), Column (d).
(11)
Total Support, Total
3C1E $
Enter the amount from Part XIII, Line 3c(1), Column (e).
Form 990-PF - Section 11¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
Note:¶
Note:¶
If the return is for a prior year, "11" edits to the left of the lines to be entered. The line items remain the same.
(2)
Support from General Public Column (a)
3C2A $
Enter the amount from Part XIII, Line 3c(2), Column (a).
(3)
Support from General Public Column (b)
3C2B $
Enter the amount from Part XIII, Line 3c(2), Column (b).
(4)
Support from General Public Column (c)
3C2C $
Enter the amount from Part XIII, Line 3c(2), Column (c).
(5)
Support from General Public Column (d)
3C2D $
Enter the amount from Part XIII, Line 3c(2), Column (d).
(6)
Support from General Public Total
3C2E $
Enter the amount from Part XIII, Line 3c(2), Column (e).
(7)
Gross Investment Income Column (a)
3C4A $
Enter the amount from Part XIII, Line 3c(4), Column (a).
(8)
Gross Investment Income Column (b)
3C4B $
Enter the amount from Part XIII, Line 3c(4), Column (b).
(9)
Gross Investment Income Column (c)
3C4C $
Enter the amount from Part XIII, Line 3c(4), Column (c).
(10)
Gross Investment Income Column (d)
3C4D $
Enter the amount from Part XIII, Line 3c(4), Column (d).
(11)
Gross Investment Income Total
3C4E $
Enter the amount from Part XIII, Line 3c(4), Column (e).
(12)
Future Grants, 3b Total
XV3B $
Enter the amount from Part XIV, Line 3b, Total line.
Form 990-PF - Section 12¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Program Services Revenue a, Column (d)
XVIA1AD $
Enter the amount from Part XV-A, Line 1a, Column (d).
(3)
Program Service Revenue a, Column (e)
1AE $
Enter the amount from Part XV-A, Line 1a, Column (e).
(4)
Program Service Revenue b, Column (d)
1BD $
Enter the amount from Part XV-A, Line 1b, Column (d).
(5)
Program Service Revenue b, Column (e)
1BE $
Enter the amount from Part XV-A, Line l b, Column (e).
(6)
Program Service Revenue c, Column (d)
1CD $
Enter the amount from Part XV-A, Line 1c, Column (d).
(7)
Program Service Revenue c, Column (e)
1CE $
Enter the amount from Part XV-A, Line 1c, Column (e).
(8)
Program Service Revenue d, Column (d)
1DD $
Enter the amount from Part XV-A, Line 1d, Column (d).
(9)
Program Service Revenue d, Column (e)
1DE $
Enter the amount from Part XV-A, Line 1d, Column (e).
(10)
Program Service Revenue e, Column (d)
1ED $
Enter the amount from Part XV-A, Line 1e, Column (d).
(11)
Program Service Revenue e, Column (e)
1EE $
Enter the amount from Part XV-A, Line 1e, Column (e).
(12)
Program Service Revenue f, Column (d)
1FD $
Enter the amount from Part XV-A, Line 1f, Column (d).
(13)
Program Service Revenue f, Column (e)
1FE $
Enter the amount from Part XV-A, Line 1f, Column (e).
(14)
Fees and Contracts from Government g, Column (d)
1GD $
Enter the amount from Part XV-A, Line 1g, Column (d).
(15)
Fees and Contracts from Government g, Column (e)
1GE $
Enter the amount from Part XV-A, Line 1g, Column (e).
(16)
Membership Dues Column (d)
2D $
Enter the amount from Part XV-A, Line 2, Column (d).
(17)
Membership Dues Column (e)
2E $
Enter the amount from Part XV-A, Line 2, Column (e).
(18)
Interest on Savings Column (d)
3D $
Enter the amount from Part XV-A, Line 3, Column (d).
(19)
Interest on Savings Column (e)
3E $
Enter the amount from Part XV-A, Line 3, Column (e).
(20)
Dividends and Interest Column (d)
4D $
Enter the amount from Part XV-A, Line 4, Column (d).
(21)
Dividends and Interest Column (e)
4E $
Enter the amount from Part XV-A, Line 4, Column (e).
(22)
Debt-Financed Property Column (d)
5AD $
Enter the amount from Part XV-A, Line 5a, Column (d).
(23)
Debt-Financed Property Column (e)
5AE $
Enter the amount from Part XV-A, Line 5a, Column (e).
(24)
Net Rental Income/Loss Column (d)
6D $
Enter the amount from Part XV-A, Line 6, Column (d).
(25)
Net Rental Income/Loss Column (e)
6E $
Enter the amount from Part XV-A, Line 6, Column (e).
(26)
Other Investment Income Column (d)
7D $
Enter the amount from Part XV-A, Line 7, Column (d).
(27)
Other Investment Income Column (e)
7E $
Enter the amount from Part XV-A, Line 7, Column (e).
(28)
Gain/Loss From Sales Column (d)
8D $
Enter the amount from Part XV-A, Line 8, Column (d).
(29)
Gain/Loss From Sales Column (e)
8E $
Enter the amount from Part XV-A, Line 8, Column (e).
(30)
Net Income/Loss Special Events Column (d)
9D $
Enter the amount from Part XV-A, Line 9, Column (d).
(31)
Net Income/Loss Special Events Column (e)
9E $
Enter the amount from Part XV-A, Line 9, Column (e).
(32)
Gross Profit/Loss From Sales Column (d)
10D $
Enter the amount from Part XV-A, Line 10, Column (d).
(33)
Gross Profit/Loss From Sales Column (e)
10E $
Enter the amount from Part XV-A, Line 10, Column (e).
Form 990-PF - Section 13¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Cash Transfer From?
XVII1A1
Enter a yes or no from the yes/no box from Part XVI, Line 1a(1).
(3)
Other Assets?
1A2
Enter a yes or no from the yes/no box from Part XVI, Line 1a(2).
(4)
Sales of Assets?
1B1
Enter a yes or no from the yes/no box from Part XVI, Line 1b(1).
(5)
Purchase of Assets?
1B2
Enter a yes or no from the yes/no box from Part XVI, Line 1b(2).
(6)
Rental?
1B3
Enter a yes or no from the yes/no box from Part XVI, Line 1b(3).
(7)
Reimbursement?
1B4
Enter a yes or no from the yes/no box from Part XVI, Line 1b(4).
(8)
Loans?
1B5
Enter a yes or no from the yes/no box from Part XVI, Line 1b(5).
(9)
Performance of Services?
1B6
Enter a yes or no from the yes/no box from Part XVI, Line 1b(6).
(10)
Sharing of?
L1C
Enter a yes or no from the yes/no box from Part XVI, Line 1c.
(11)
Preparer PTIN
PTIN
Enter the Prepare's PTIN.
(12)
Preparer EIN
PEIN
Enter the preparer's EIN.
(13)
Preparer Telephone #
TEL#
Enter the Preparer's phone number.
Form 990-PF - Section 20, Form 965¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Net 965 Tax Liability
D1 TAX $
Enter the amount from Part I column (d) line 1.
(3)
Form 965-B Part I Indicator
IND
Enter "1" if additional information is present in Part I.
Form 990-PF - Section 60, Form 8050¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT
Press
(2)
Routing Transit Number
60RTN
Enter the routing number from F8050, line1.
(3)
Deposit Account Number
60DAN
Enter the account number from F8050, line 2.
Form 990-T - Section 01¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4
(5)
Employer Identification Number
EIN
Enter the EIN from the preprinted label or from EIN block.
See standard rules in IRM 3.24.38.
For error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under title of form.
If not edited or underlined, press
For special instructions see IRM 3.24.38.
(10)
Condition Codes
CCC
Enter the edited codes from the dotted portion of Line 2–4a.
If a Condition Code is illegible, enter a "#" in its place.
(11)
Filling Field (VIN Portal Information Field)
Generate blank
(11)
Return Processing Code
01RPC
Enter the edited codes on Page 1, in the right margin next to line 1.
(12)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
If a "G" Condition Code is present and the return is a non-remittance, end the document after this element.
For special instructions see IRM 3.24.38.
(13)
Exempt Sub Section
BOXB
Enter the edited 2-digit code from Box B.
(14)
Organization Code
ORGCD
Enter the edited code from the right margin of box F/G.
(15)
In Care of Name Line
C/O NAME
Enter the in care of name as shown.
Note:¶
Downstream processing generates a (%) sign.
(16)
Foreign Address
FGN ADD
Enter the foreign street address, if shown.
For additional instructions see IRM 3.24.38.
(17)
Street Address
ADDR
Enter the street address from the address line.
If a "G" Condition Code is present, do NOT enter any of the address information, even if prompted to do so. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
For specific instructions see IRM 3.24.38.
(18)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(19)
State
ST
Enter the standard state abbreviation from the city/state line.
If a Major City Code was entered, press
If a foreign address, enter a period (.).
See IRM 3.24.38).
(20)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
(21)
Number of Organizations Trade or Business
NOTB
Enter the amount Item H, first question.
Note:¶
Form 990-T - Section 02, Form 5800 - Edit Sheet¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
LN1
Enter the edited digits from the bottom left margin of the return.
If a "G" Condition Code is present and return is a remittance, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Indicator/Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digit from Line 4, Form 5800.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800, in MMDDYY format.
For special instructions, see IRM 3.24.38.
(7)
Penalty/Interest Code
LN6
Enter the edited digit from Line 6, Form 5800.
(8)
Installment Sales Indicator
LN7
Enter the edited digit from Line 7, Form 5800.
(9)
Missing Schedule Code
LN8
Enter the edited digits from Line 8, Form 5800.
(10)
Form 2439 Regulated Investment Company Credit
LN9
Enter the edited amount from Line 9, Form 5800.
(11)
Form 5735 Possessions Credit
L10
Enter the edited amount from Line 10, Form 5800.
(12)
Form 8586 Low Income Housing Credit
L11
Enter the edited amount from Line 11, Form 5800.
Form 990-T - Section 03¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance
RMT
Enter the edited amount shown in the margin at the top of the return.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Was Corporation a Subsidiary Member
?IY/N
Enter a yes or no from the yes/no box from Line K.
(4)
Parent Corporation Name Control
?INC
Enter the edited or underlined Name Control from Line K.
(5)
Parent Corporation EIN
?IEIN
Enter the EIN from Line K.
(6)
Gross Receipts Less Returns & Allowances
L1C $
Enter the amount from Part I, Line 1c, Column A. (2019 and prior revisions only)
(7)
Cost of Goods Sold
LN2 $
Enter the amount from Part I, Line 2, Column A. (2019 and prior revisions only)
(8)
Investment Income 501(c)
L9(C) $
Enter the amount from Part I, Line 9, Column (C). (2019 and prior revisions only)
(9)
Dispose of Any Investments
12...$
Enter the amount from the dotted portion of line 12. (2019 and prior revisions only)
(10)
Total Unrelated Trade or Business Income
13(A) $
Enter the amount from Part I, Line 13, Column (A). (2019 and prior revisions only)
(11)
Total Expenses
13(B) $
Enter the amount from Part I, Line 13, Column (B). (2019 and prior revisions only)
(12)
Total Net
13(C) $
Enter the amount from Part I, Line 13, Column (C). (2019 and prior revisions only)
(13)
Total Deductions
L29 $
Enter the amount from Part II, Line 28. (2019 and prior revisions only)
(14)
Net Operating Loss
L31 $
Enter the amount from Part II, Line 31. (2019 and prior revisions only)
(15)
Taxable Income Computed From all Unrelated Trades or Businesses
LI1 $
Enter the amount from Part I, Line 1.
(16)
Amount Disallowed Fringes
LI2 $
Enter the amount from Part I, Line 2.
(17)
Charitable Contributions
LI4 $
Enter the amount from Part I, Line 4.
(18)
Total of Unrelated Tax pre NOLS
LI5 $
Enter the amount from Part I, Line 5.
(19)
Deduction for Net Operating Loss
LI6 $
Enter the amount from Part I, Line 6.
(20)
Unrelated Business Taxable Income
LI7 $
Enter the amount from Part I, Line 7.
(21)
Specific Deduction
LI8 $
Enter the amount from Part I, Line 8.
(22)
Section 199A Deduction
LI9 $
Enter the amount from Part I, Line 9.
(23)
Total Deductions 2020 and Subsequent
LI10 $
Enter the amount from Part I, Line 10.
(24)
Unrelated Business Taxable Income
LI11 $
Enter the amount from Part I, Line 11.
Form 990-T - Section 04¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Controlled Group Code
L39 RT
Enter the edited digit to the right of Part IV, Line 40 check box. (2019 and prior revision only)
(3)
1st Income Bracket
1STINCA1$
Enter the amount from Part III, Line 35a(1).
Enter Only for 2017 and prior tax periods.
(4)
2nd Income Bracket
2NDINCA2$
Enter the amount from Part III, Line 35a(2).
Enter Only for 2017 and prior tax periods.
(5)
3rd Income Bracket
3RDINCA3$
Enter the amount from Part III, Line 35a(3).
Enter Only for 2017 and prior tax periods.
(6)
Additional 5% Tax
5%TAXB1$
Enter the amount from Part III, Line 35b(1).
Enter Only for 2017 and prior tax periods.
(7)
Additional 3% Tax
3%TAXB2$
Enter the amount from Part III, Line 35b(2).
Enter Only for 2017 and prior tax periods.
(8)
Corp. Income Tax Taxpayer
LII1 $
Enter the amount from Part II, Line 1.
(9)
Trust Income Tax
LII2 $
Enter the amount from Part II, Line 2.
(10)
Proxy Tax
LII3 $
Enter the amount from Part II, Line 3.
(11)
Chapter 1 Tax recapture from Form 4255
LII4A $
Enter the amount from Part II, Line 4a
(12
Other Additions to Tax
LII4B $
Enter the amount from Part II, Line 4b.
(13)
Alternative Minimum Tax
LII5 $
Enter the amount from Part II, Line 5.
(14)
Non Compliant Hospital Facility Income
LII6 $
Enter the amount from Part II, Line 6.
(15)
Total (Gross Tax)
LII7 $
Enter the amount from Part II, Line 7.
(16)
Foreign Tax Credit
III1A $
Enter the amount from Part III, Line 1a.
(17)
Other Tax Credits
III1B $
Enter the amount from Part III, Line 1b.
(18)
General Business Credit
III1C $
Enter the amount from Part III, Line 1c.
(19)
Credit Prior Year Minimum Tax
III1D $
Enter the amount from Part III, Line 1d.
(20)
Total Statutory Credits
III1E $
Enter the amount from Part III, Line 1e.
(21)
Credit Recapture from Form 4255
III3A
Enter the amount from Part III, Line 3a.
(22)
Recapture Taxes
III3F $
Enter the amount from Part III, Line 3f.
(23)
Total Tax
III4
Enter the amount from Part III, Line 4.
(24)
Net 965 Tax Liability
III5A
Enter the amount from Part III, Line 5a.
(25)
Net 1062 Tax Liability
III5B
Enter the amount from Part III, Line 5b.
(26)
Prior Year Overpayment Credit
III6A
Enter the amount from Part III, Line 6a.
(27)
ES Payments
III6B
Enter the amount from Part III, Line 6b.
(28)
Tax Deposited—Form 8868
III6C
Enter the amount from Part III, Line 6c.
(29)
Tax Withheld at Source
III6D
Enter the amount from Part III, Line 6d.
(30)
Backup Withholding
III6E
Enter the amount from Part III, Line 6e.
(31)
Small Business Health Care Tax Credit
III6F
Enter the amount from Part III, Line 6f.
(32)
Deemed payment election
III6G
Enter the amount from Part III, Line 6g.
(33)
Credit from a RIC or REIT
III6H
Enter the amount from Part III, Line 6h.
(34)
Credit for federal tax paid on fuels
III6I
Enter the amount from Part III, Line 6i.
(35)
Other Payments and Credits
III6J
Enter the amount from Part III, Line 6j.
(36)
Net Tax Liability Deferred on Sale of Farmland
III5K
Enter the amount from Part III, Line 6k.
(37)
ES Penalty
III8
Enter the amount from Part III, Line 8.
(38)
Tax Due/Overpayment
9/10
Enter amount shown on Part III, Line 9 followed by pressing
If no amount present on Line 9, enter the amount from Line 10 with a MINUS (−).
If both lines have entries, enter the amount from Line 10 and press
(39)
Credit Elect
L11
Enter the amount from the first box, Part III, Line 11.
(40)
Discuss with Preparer Checkbox
CKBX
Enter a "1" if the Yes box is checked.
(41)
Preparer's /PTIN
PTIN
Enter the Preparer's PTIN.
(42)
Preparer's EIN
PEIN
Enter the Preparer's EIN from the Preparer's EIN box.
(43)
Preparer's Telephone Number
TEL#
Enter the Preparer's phone number from the Preparer's phone number box.
Form 990-T - Section 07, Form 1041 - Schedule I¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Alternative Tax NOLD
L22 $
Enter the amount from Schedule I, Part I, Line 22.
(3)
Total Adjustments and Tax Preference
L23 $
Enter the amount from Schedule I, Part I, Line 23.
Form 990-T - Section 08, Form 1041 - Schedule D, Form 4952¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Schedule D Net Short-Term Gain/Loss Estates/Trusts
D17(2) $
Enter the amount from Schedule D, Part III, Line 17, Column (2).
(3)
Net Long-Term Gain/Loss for Year
18A(2) $
Enter the amount from Schedule D, Part III, Line 18a, Column (2).
(4)
Unrecaptured Section 1250 Estates/Trusts
18B(2) $
Enter the amount from Schedule D, Part III, Line 18b, Column (2).
(5)
28% Rate Gain/Loss
18C(2) $
Enter the amount from Schedule D, Part III, Line 18c, Column (2).
(6)
Total Net Gain/Loss Estates/Trusts
19(2) $
Enter the amount from Schedule D, Part III, Line 19, Column (2).
(7)
Estate/Trust Qualified Dividends
L23 $
Enter the amount from Schedule D, Part V, Line 23.
(8)
Tax on Taxable Income
L45 $
Enter the amount from Schedule D, Part V, Line 45.
(9)
Form 4952 Line 4e
4952L4E $
Enter the amount from Form 4952, Part II, Line 4e.
(10)
Form 4952 Line 4g
4952L4G $
Enter the amount from Form 4952, Part II, Line 4g.
Form 990-T - Section 10, Form 8949¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Dispose of Any Investments
ZCKBX
For Form 990-T enter only. Enter the numeric digit from Dispose of Any Investments Checkbox from Schedule D
0 = no
1 = yes
(3)
Employer Identification Number
ZPTI 1(A)
Enter the EIN from Form 8949 Part I Line 1 column (a).
Note:¶
Enter the underlined data or enter only if there is a "Z" in Column (f).
(4)
Date Acquired
ZPTI 1(B)
Enter the date from Form 8949 Part I Line 1 column (b).
Note:¶
Enter the underlined data or enter only if there is a Z in Column (f).
(5)
Amount of Adjustment
ZPTI 1(G) $
Enter the amount from Form 8949 Part I Line 1 column (g).
Note:¶
Enter the underlined data or enter only if there is a "Z" in Column (f).
(6)
Part I 8949 Indicator
ZPTI IND
Enter "1" if additional information is present in Part I.
(7)
EIN
YPTI 1(A)
Enter the EIN from Form 8949 Part I Line 1 column (a).
Note:¶
Enter the underlined data or enter only if there is a "Y" in Column (f).
(8)
Date Sold or Disposed
YPTI 1(B)
Enter the date from Form 8949 Part I Line 1 column (b).
Note:¶
Enter the underlined data or enter only if there is a "Y" in Column (f).
(9)
Recaptured Deferral
YPTI 1(G) $
Enter the amount from Form 8949 Part I Line 1 column (g).
Note:¶
Enter the underlined data or enter only if there is a "Y" in Column (f).
(10)
Part I 8949 Indicator
YPTI IND
Enter "1" if additional Y information is present in Part I.
(11)
EIN
ZPTII 1 (A)
Enter the EIN from Form 8949Part II Line 1 column (a).
Note:¶
Enter the underlined data or enter only if there is a "Z" in Column (f).
(12)
Date Acquired
ZPTII 1 (B)
Enter the date from Form 8949 Part II Line 1 column (b).
Note:¶
Enter the underlined data or enter only if there is a "Z" in Column (f).
(13)
Amount of Adjustment
ZPTII 1 (G) $
Enter the EIN from Form 8949 Part II Line 1 column (g).
Note:¶
Enter the underlined data or enter only if there is a "Z" in Column (f).
(14)
Part I Form 8949 Indicator
ZPTII IND
Enter 1 if additional Y information is present in Part I.
(15)
EIN
YPTII 1 (A)
Enter the EIN from Form 8949 Part II Line 1 column (a).
Note:¶
Enter the underlined data or enter only if there is a "Y" in Column (f).
(16)
Date Sold or Disposed
YPTII 1(B) V
Enter the date from Form 8949 Part II Line 1 column (b).
Note:¶
Enter the underlined data or enter only if there is a "Y" in Column (f).
(17)
Recaptured Deferral
YPTII 1(G) $
Enter the amount from Form 8949 Part II Line 1 column (g).
Note:¶
Enter the underlined data or enter only if there is a "Y" in Column (f).
(18)
Part II 8949 Indicator
YPTII IND
Enter "1" if additional Y information is present in Part II.
Form 990-T - Section 13, Form 8995/8995A¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part IV Qualified Business Income
L5/L27
Enter the amount from Line 5 or Line 27 as follows:
Enter the amount from Form 8995 Line 5, if present and press Enter.
Enter the amount from Form 8995-A, Part IV, Line 27, if present and press Enter.
(3)
Part IV REIT/PTP Component
L9/L31
Enter the amount from Line 9 or Line 31 as follows:
Enter the amount from Form 8995, Line 9, if present and press Enter.
Enter the amount from Form 8995-A, Part IV, Line 31 if present and press Enter.
(4)
Part IV Net Capital Gains
L12/L34
Enter the amount from line 12 or line 34 as follows:
Enter the amount from Form 8995 line 12, if present, and press Enter.
Enter the amount from Form 8995-A Part IV line 34, if present, and press Enter.
(5)
Part IV Domestic Production Activities Section 199A(g)
L38
Enter the amount from Form 8995-A Part IV line 38.
Form 990-T - Section 15, Form 4136¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Amount of Claim 1
AMT1(D) $
Enter the first amount shown on Column (d).
(3)
Credit Reference Number 1
CRN1(E)
Enter the CRN from Column (e) that corresponds with the first amount entered.
(4)
Amount of Claim 2
AMT2(D) $
Enter the second amount shown on Column (d).
(5)
Credit Reference Number 2
CRN2(E)
Enter the CRN from Column (e) that corresponds with the second amount entered.
(6)
Amount of Claim 3
AMT3(D) $
Enter the third amount shown on Column (d).
(7)
Credit Reference Number 3
CRN3(E)
Enter the CRN from Column (e) that corresponds with the third amount entered.
(8)
Amount of Claim 4
AMT4(D) $
Enter the fourth amount shown on Column (d).
(9)
Credit Reference Number 4
CRN4(E)
Enter the CRN from Column (e) that corresponds with the fourth amount entered.
(10)
Amount of Claim 5
AMT5(D) $
Enter the fifth amount shown on Column (d).
(11)
Credit Reference Number 5
CRN5(E)
Enter the CRN from Column (e) that corresponds with the fifth amount entered.
(12)
Amount of Claim 6
AMT6(D) $
Enter the sixth amount shown on Column (d).
(13)
Credit Reference Number 6
CRN6(E)
Enter the CRN from Column (e) that corresponds with the sixth amount entered.
(14)
Amount of Claim 7
AMT7(D) $
Enter the seventh amount shown on Column (d).
(15)
Credit Reference Number 7
CRN7(E)
Enter the CRN from Column (e) that corresponds with the seventh amount entered.
(16)
Amount of Claim 8
AMT8(D) $
Enter the eighth amount shown on Column (d).
(17)
Credit Reference Number 8
CRN8(E)
Enter the CRN from Column (e) that corresponds with the eighth amount entered.
(18)
Amount of Claim 9
AMT9(D) $
Enter the ninth amount shown on Column (d).
(19)
Credit Reference Number 9
CRN9(E)
Enter the CRN from Column (e) that corresponds with the ninth amount entered.
(20)
Amount of Claim 10
AMT10(D) $
Enter the tenth amount shown on Column (d).
(21)
Credit Reference Number 10
CRN10(E)
Enter the CRN from Column (e) that corresponds with the tenth amount entered.
(22)
Amount of Claim 11
AMT11(D) $
Enter the eleventh amount shown on Column (d).
(23)
Credit Reference Number 11
CRN11(E)
Enter the CRN from Column (e) that corresponds with the tenth amount entered.
(24)
Amount of Claim 12
AMT12(D) $
Enter the twelfth amount shown on Column (d).
(25)
Credit Reference Number 12
CRN12(E)
Enter the CRN from Column (e) that corresponds with the twelfth amount entered.
(26)
Amount of Claim 13
AMT13(D) $
Enter the thirteenth amount shown on Column (d).
(27)
Credit Reference Number 13
CRN13(E)
Enter the CRN from Column (e) that corresponds with the thirteenth amount entered.
(28)
Amount of Claim 14
AMT14(D) $
Enter the fourteenth amount shown on Column (d).
(29)
Credit Reference Number 14
CRN14(E)
Enter the CRN from Column (e) that corresponds with the fourteenth amount entered.
(30)
Amount of Claim 15
AMT15(D) $
Enter the fifteenth amount shown on Column (d).
(31)
Credit Reference Number 15
CRN15(E)
Enter the CRN from Column (e) that corresponds with the fifteenth amount entered.
(32)
Amount of Claim 16
AMT16(D) $
Enter the sixteenth amount shown on Column (d).
(33)
Credit Reference Number 16
CRN16(E)
Enter the CRN from Column (e) that corresponds with the sixteenth amount entered.
(34)
Amount of Claim 17
AMT17(D) $
Enter the seventeenth amount shown on Column (d).
(35)
Credit Reference Number 17
CRN17(E)
Enter the CRN from Column (e) that corresponds with the seventeenth amount entered.
(36)
Amount of Claim 18
AMT18(D) $
Enter the eighteenth amount shown on Column (d).
(37)
Credit Reference Number 18
CRN18(E)
Enter the CRN from Column (e) that corresponds with the eighteenth amount entered.
(38)
Amount of Claim 19
AMT19(D) $
Enter the nineteenth amount shown on Column (d).
(39)
Credit Reference Number 19
CRN19(E)
Enter the CRN from Column (e) that corresponds with the nineteenth amount entered.
(40)
Amount of Claim 20
AMT20(D) $
Enter the twentieth amount shown on Column (d).
(41)
Credit Reference Number 20
CRN20(E)
Enter the CRN from Column (e) that corresponds with the twentieth amount entered.
Form 990-T - Section 17, Form 4626, 2017 and prior years only¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Pre-Adjustment AMTI
LN3 $
Enter the amount from Line 3.
(3)
Adjusted Current Earnings
L4E $
Enter the amount from Line 4e.
(4)
Alternative Tax Net Operating Loss Deduction
LN6 $
Enter the amount from Line 6.
(5)
Tentative Minimum Tax
L12 $
Enter the amount from Line 12.
Form 990-T - Section 19, Form 8978¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
BBA Audit and AAR Filing Check Box
CHKBX
1 = BBA Audit,
2 = AAR Filing,
3 = both, 0 = default (no box checked or section not present)
(3)
Total Additional Reporting Year Tax
L14
Enter the amount from Part I, Line 14.
(4)
Total Penalties
L16
Enter the amount from Part II, Line 16.
(5)
Total Interest
L18
Enter the amount from Part III, Line 18.
Form 990-T - Section 20, Forms 965-A and B¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT
Press
(2)
Election or Transfer Year
A1 YEAR
Enter the last two positions of the tax year Part I, column (a).
(3)
Part I Form 965-A Indicator
PTI IND
Enter "1" if additional information is present on line 6 Part I.
(4)
Net 965 Tax Liability Transferred
J1 TAX $
Enter the amount from Part I, column (j).
(5)
Tax Identification Number
K1 TIN
Enter the TIN from Part I, column (k).
(6)
Part IV Indicator
PTIV IND
Enter "1" if additional information is present in Part IV Line 6.
(7)
Election or Transfer Year
A2 YEAR
Enter the last two positions of the tax year Part I, column (a).
(8)
Net 965 Tax Liability Transferred
J2 TAX $
Enter the amount from Part I, column (j).
(9)
Tax Identification Number
K2 TIN
Enter the TIN from Part I, column (k).
(10)
Election or Transfer Year
A3 YEAR
Enter the last two positions of the tax year from Part I, column (a).
(11)
Net 965 Tax Liability Transferred
J3 TAX $
Enter the amount from Part I, column (j).
(12)
Tax Identification Number
K3 TIN
Enter the TIN from Part I, column (k).
(13)
Election or Transfer Year
A4 YEAR
Enter the last two positions of the tax year Part I, column (a).
(14)
Net 965 Tax Liability Transferred
J4 TAX $
Enter the amount from Part I, column (j).
(15)
Tax Identification Number
K4 TIN
Enter the TIN from Part I, column (k).
(16)
Election or Transfer Year
A5 YEAR
Enter the last two positions of the tax year Part I, column (a).
(17)
Net 965 Tax Liability Transferred
J5 TAX $
Enter the amount from Part I, column (j).
(18)
Tax Identification Number
K5 TIN
Enter the TIN from Part I, column (k).
(19)
Net 965 Tax Liability Triggered
F1 TAX $
Enter the amount from Part IV, column (f).
(20)
Net 965 Tax Liability Triggered
F2 TAX $
Enter the amount from Part IV, column (f).
(21)
Net 965 Tax Liability Triggered
F3 TAX $
Enter the amount from Part IV, column (f).
(22)
Net 965 Tax Liability Triggered
F4 TAX $
Enter the amount from Part IV, column (f).
(23)
Net 965 Tax Liability Triggered
F5 TAX $
Enter the amount from Part IV, column (f).
(24)
Total
I1 TOTAL $
Enter the amount from Part IV, column (i).
(25)
Election or Transfer Year
A1 YEAR
Enter the year from Part I, Line 1, column a.
(26)
Net 965 Tax Liability Transferred
H1 TAX $
Enter the amount from Part I, Line 1, column h.
(27)
Tax Identification Number
I1 TIN
Enter the TIN from Part I, Line 1, column i.
(28)
Election or Transfer Year
A2 YEAR
Enter the date from Part I, Line 2, column a.
(29)
Net 965 Tax Liability Transferred
H2 TAX $
Enter the amount from Part I, Line 2, column h.
(30)
Tax Identification Number
I2 TIN
Enter the TIN from Part I, Line 2, column i.
(31)
Election or Transfer Year
A3 YEAR
Enter the year from Part I, Line 3, column a.
(32)
Net 965 Tax Liability Transferred
H3 TAX $
Enter the amount from Part I, Line 3, column h.
(33)
Tax Identification Number
I3 TIN
Enter the TIN from Part I, Line 3, column i.
(34)
Election or Transfer Year
A4 YEAR
Enter the date from Part I, Line 4, column a.
(35)
Net 965 Tax Liability Transferred
H4 Tax $
Enter the amount from Part I, Line 4, column h.
(36)
Tax Identification Number
I4 TIN
Enter the TIN from Part I, Line 4, column i.
(37)
Election or Transfer Year
A5 YEAR
Enter the date from Part I, Line 5, column a.
(38)
Net 965 Tax Liability Transferred
H5 TAX $
Enter the amount from Part I, Line 5, column h.
(39)
Tax Identification Number
I5 TIN
Enter the TIN from Part I, Line 5, column i.
(40)
Form 965-B Indicator
B IN
Enter the edited digit from Form 965-B, Right Margin Part I.
Form 990-T - Section 21, Form 8941¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Shop Box
21BX
Enter a
1 if the Shop Box on Form 8941 is checked yes.
2 if checked no
3 if both boxes are checked
Enter if no boxes are checked and the system generates a 0.
(3)
Employer Identification Number
21B
Enter the EIN from box b.
(4)
Previous Form 8941 Filed
21C
Enter a
1 if the previous filed Form 8941 (C) checkbox is checked yes,
2 if check no,
3 if both boxes checked
default “0” if no boxes are checked.
(5)
Number of Employees
L1
Enter the number from Line 1.
Note:¶
If greater than 9999 just enter 9999. If a value is present but less than 1 enter a 1.
(6)
Number of Full Time Employees Tax Year
L2
Enter the number from Line 2.
Note:¶
Round to the next lowest whole number if not a whole number. If less than 1 enter a 1.
(7)
Average Annual Wages
LN3 $
Enter the amount from Line 3.
(8)
Health Insurance Premiums Paid
LN4 $
Enter the amount from Line 4.
(9)
Premiums You Would Have Paid
LN5 $
Enter the amount from Line 5.
(10)
Smaller office 4 or 5
LN6 $
ENTER
Enter the amount from Line 6.
(11)
Multiply Line 6 by 25%
LN7 $
ENTER
Enter the amount from Line 7.
(12)
Amount of State Subsidies paid/tax credits
L10 $
Enter the amount from Line 10.
(13)
If Line 12 is zero
L13
Enter the number from Line 13.
(14)
Number of Employees you Would Have Entered on Line 2
L14
Enter the number from Line 14.
Note:¶
If greater than 99 enter 99.
(15)
Add Lines 12 and 15
L16 $
Enter the amount from Line 16.
(16)
Cooperatives, Estates, Trusts Credit
L18 $
Enter the amount from Line 18.
(17)
Payroll Taxes
L19 $
Enter the amount from Line 19.
(18)
Tax Exempt Small Employers
L20 $
Enter the amount from Line 20.
Form 990-T - Section 22, Form 5884-B¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Total of Line 9, Columns (a) through (c)
L10 $
Enter the amount from Line 10
(3)
Number of retained workers
L11
Enter the number from Line 11.
Form 990-T - Section 23, Form 3800¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Form 7207 Registration Number 1B
1BB
Enter the number from Part III, Line 1b, Column b.
(3)
Form 7207 Credit Transfer Election Amount 1B
1BF$
<ENTER +/->
Enter the amount from Part III, Line 1b, Column f.
(4)
Form 7207 Credit Allowed After Passive Activity Limit 1B
1BG$
Enter the amount from Part III, Line 1b, Column g.
(5)
Form 7207 Gross Elective Payment Election Amount 1B
1BH$
Enter the amount from Part III, Line 1b, Column h.
(6)
Form 7207 Net Elective Payment Election Amount Line 1B Total
1BJ$
Enter the amount from Part III, Line 1b, Column j.
7
Form 3468 Registration Number 1D
1DB
Enter the number from Part III, Line 1d, Column b.
(8)
Form 3468 Credit Transfer Election Amount 1D
1DF$
<ENTER +/->
Enter the amount from Part III, Line 1d, Column f.
(9)
Form 3468 Credit Allowed After Passive Activity Limit
1DG$
Enter the amount from Part III, Line 1d, Column g.
(10)
Form 3468 Gross Elective Payment Election 1D
1DH$
Enter the amount from Part III, Line 1d, Column h.
(11)
Form 3468 Net Elective Payment Election Credit Amount 1D
1DJ$
Enter the amount from Part III, Line 1d, Column j.
(12)
Form 8835, Part II Registration Number 1F
1FB
Enter the number from Part III, Line 1f, Column b.
(13)
Form 8835 , Part II Credit Transfer Election Amount 1F
1FF$
<ENTER +/->
Enter the amount from Part III, Line 1f, Column f.
(14)
Form 8835, Part II Credit Allowed After Passive Activity Limit 1F
1FG$
Enter the amount from Part III, Line 1f, Column g.
(15)
Form 7210 Registration Number 1G
1GB
Enter the number from Part III, Line 1g, Column b.
(16)
Form 7210 Credit Transfer Election Amount 1G
1GF$
<ENTER +/->
Enter the amount from Part III, Line 1g, Column f.
(17)
Form 7210 Credit Allowed After Passive Activity Limit 1G
1GG$
Enter the amount from Part III, Line 1g, Column g.
(18)
Form 7210 Gross Elective Payment Election 1G
1GH$
Enter the amount from Part III, Line 1g, Column h.
(19)
Form 7210 Net Elective Payment Election Credit Amount 1G
1GJ$
Enter the amount from Part III, Line 1g, Column j.
Form 990-T - Section 24, Form 3800¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Form 3468 , Part IV Registration Number 1O
1OB$
Enter the number from Part III, Line 1o, Column b.
(3)
FILLER-SECT24-G
1OF$
N/A
(4)
Form 3468, Part IV Credit Allowed After Passive Activity Limit 1O
1OG$
Enter the number from Part III, Line 1o, Column g.
(5)
Form 3468, Part IV Gross Elective Payment Election 1O
1OH$
Enter the number from Part III, Line 1o, Column h.
(6)
Form 3468, Part IV Net Elective Payment Election Credit Amount 1O
1OJ$
Enter the number from Part III, Line 1o, Column j.
(7)
Form 7218 Registration Number 1Q
1QB
Enter the amount from Part III, Line 1q, Column b.
(8)
Form 7218 Credit Transfer Election Amount 1Q
1QF$
<ENTER +/->
Enter the amount from Part III, Line 1q, Column f.
(9)
Form 7218 Credit Allowed After Passive Activity Limit 1Q
1QG$
Enter the amount from Line 1g, Column g.
(10)
Form 7218 Gross Elective Payment Election 1Q
1QH$
Part III, Line 1q, Column h.
(11)
Form 7218 Net Elective Payment Election Credit Amount 1Q
1QJ$
Part III, Line 1q, Column j.
(12)
Form 8911 Registration Number 1S
1SB
Enter the number from Part III, Line 1s, Column b.
(13)
Form 8911 Credit Transfer Election Amount 1S
1SF$
<ENTER +/->
Enter the amount from Part III, Line 1s, Column f.
(14)
Form 8911 Credit Allowed After Passive Activity Limit 1S
1SG$
Enter the amount from Part III, Line 1s, Column g.
(15)
Form 8911 Gross Elective Payment Election 1S
1SH$
Enter the amount from Part III, Line 1s, Column h.
(16)
Form 8911 Net Elective Payment Election Credit Amount 1S
1SJI$
Enter the amount from Part III, Line 1s, Column j.
(17)
Form 7213, Part II Registration 1U
1UB
Enter the number from Part III, Line 1u, Column b.
(18)
Form 7213, Part II Credit Transfer Election Amount 1U
1UF$
<ENTER +/->
Enter the amount from Part III, Line 1u, Column f.
(19)
Form 7213, Part II Credit Allowed After Passive Activity Limit 1U
1UG$
Enter the amount from Part III, Line 1u, Column g.
(20)
Form 7213, Part II Gross Elective Payment Election 1U
1UH$
Enter the amount from Part III, Line 1u, Column h.
(21)
Form 7213, Part II Net Elective Payment Election Credit Amount 1U
1UJ$
Enter the amount from Part III, Line 1u, Column j.
(22)
Form 3468, Part V Registration Number 1V
1VB
Enter the number from Part III, Line 1v, Column b.
(23)
Form 3468, Part V Credit Transfer Election Amount 1V
1VF$
<ENTER +/->
Enter the amount from Part III, Line 1v, Column f.
(24)
Form 3468, Part V Credit Allowed After Passive Activity Limit 1V
1VG$
Enter the amount from Part III, Line 1v, Column g.
(25)
Form 3468, Part V Gross Elective Payment Election 1V
1VH$
Enter the amount from Part III, Line 1v, Column h.
(26)
Form 3468, Part V Net Elective Payment Election Credit Amount 1V
1VJ$
Enter the amount from Part III, Line 1v, Column j.
(27)
Form 8933 Registration number 1X
1XB
Enter the number from Part III, Line 1x, Column b.
(28)
Form 8933 Credit Transfer Election Amount 1X
1XF$
<ENTER +/->
Enter the amount from Part III, Line 1x, Column f.
(29)
Form 8933 Credit Allowed After Passive Activity Limit 1X
1XG$
Enter the amount from Line 1x, Column g.
(30)
Form 8933 Gross Elective Payment Election 1X
1XH$
Enter the amount from Part III, Line 1x, Column h.
(31)
Form 8933 Net Elective Payment Election Credit Amount 1X
1XJ$
Enter the amount from Part III, Line 1x, Column j.
Form 990-T - Section 25, Form 3800¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Form 8936 , Part V Registration Number 1AA
1AAB
Enter the number from Part III, Line 1aa, Column b.
(3)
Form 8936, Part V Credit Allowed After Passive Activity Limit
1AAG
Enter the amount from Part III, Line 1aa, Column g.
(4)
Form 8936, Part V Gross Elective Payment Election 1AA
1AAH$
Enter the amount from Part III, Line 1aa, Column h.
(5)
Form 8936, Part V Net Elective Payment Election Credit Amount 1AA
1AAJ$
Enter the amount from Part III, Line 1aa, Column j.
(6)
Form 7211, Registration Number 1GG
1GGB
Enter the amount from Part III, Line 1gg, Column b.
(7)
Form 7211 Credit Transfer Election Amount 1GG
1GGF$
<ENTER +/->
Enter the amount from Part III, Line 1gg, Column f.
(8)
Form 7211 Credit Allowed After Passive Activity Limit
1GGG$
Enter the amount from Part III, Line 1gg, Column g.
(9)
Form 7211 Gross Elective Payment Election 1GG
1GGH$
Enter the amount from Part III, Line 1gg Column h.
(10)
Form 7211 Net Elective Payment 1GG
1GGJ$
Enter the amount from Part III, Line 1gg Column j.
(11)
Form 3468, Part VI Registration 4A
4AB
Enter the number from Part III, Line 4a, Column b.
(12)
Form 3468, Part VI CreditTransfer Election Amount 4A
4AF$
<ENTER +/->
Enter the amount from Part III, Line 4a, Column f.
(13)
Form 3468, Part VI Credit Allowed After Passive Activity Limit
4AG$
Enter the amount from Part III, Line 4a, Column g.
(14)
Form 3468, Part VI Gross Elective Payment Election 4A
4AH$
Enter the amount from Part III, Line 4a, Column h.
(15)
Form 3468, Part V Net Elective Payment Election Credit Amount 4A
4AJ$
Enter the amount from Part III, Line 4a, Column j.
(16)
Form 8835, Part II Registration Number 4E
4EB
Enter the number from Part III, Line 4e, Column b.
(17)
Form 8835, Part II Credit Transfer Election Amount 4E
AEF$
<ENTER +/->
Enter the amount from Part III, Line 4e, Column f.
(18)
Form 8835, Part II Credit Allowed After Passive Activity Limit 4E
AEG$
Enter the amount from Part III, Line 4e, Colunm g.
(19)
Form 8835, Part II Gross Payment Election 4E
AEH$
Enter the amount from Part III, Line 4e, Column h.
(20)
Form 8835, Part II Net Elective Payment Election Credit Amount 4E
AEJ$
Enter the amount from Part III, Line 4e, Column j.
(21)
Part V indicator
VIND
Enter 1 if any Box in Part V, column b is marked.
Form 990-T - Section 27, Form 8283¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT
Press
(2)
Type of Property Donated Code
PIL2BX
Enter the alpha from Part I, Line 2 check box.
(3)
Appraised Market Value
PIL3C $
<ENTER + >
Enter the amount from Part I, Line 3, column (c).
(4)
Acquired by Donor Date
PIL3D
Enter the date from Part I, Line 3, column (d) MMYYYY.
(5)
Cost or Adjusted Basis Amount
PIL3F
<ENTER/+ >
Enter the amount from Part I, Line 3, column (f).
(6)
Appraiser Signature Indicator
PIVSIG
Enter “1” if signature present or “0” if no signature is present.
(7)
Appraiser Identifying Number
PIVIN
Enter the number from Part IV Identifying Number.
(8)
Donated Property Received Date
PVDT
Enter the date from Part V, first line in YYYYMMDD format.
(9)
Employer Identification Number
PVEIN
Enter the EIN in Part V, employer identification number.
(10)
Part V Authorized Signature Code
PVSC
Enter a 1 if signature is present and 0 if no signature is present.
(11)
Additional Form 8283 Indicator
27IND
Enter 1 is more than 1 Form 8283 or 0 if only 1 Form 8283 is present.
Form 990-T - Section 31, Form 8936¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Vehicle Identification Number (VIN)
311VI
First Schedule A, Part I, Line 2
(3)
Placed in service date
311DT
First Schedule A, Part I, Line 3
(4)
Tentative credit amount
31109
First Schedule A, Part II, Line 9
(5)
Credit amount for business use of new clean vehicle
31111
Part II, Line 11
(6)
Smaller of Line 15 or Line 16
31117
First Schedule A, Part IV, Line 17
(7)
Smaller of Line 24 or Line 25
31126
First Schedule A, Part V, Line 26
(8)
Indicator field for results of MeF check of VIN against portal
311IN
N/A
(9)
Vehicle Identification Number (VIN)
312VI
Second Schedule A, Part I, Line 2
(10)
Placed in service date
312DT
Second Schedule A, Part I, Line 3
(11)
Tentative credit amount
31209
Second Schedule A, Part II, Line 9
(12)
Credit amount for business use of new clean vehicle
31211
Part II, Line 11
(13)
Smaller of Line 15 or Line 16
31217
Second Schedule A, Part IV, Line 17
(14)
Smaller of Line 24 or Line 25
31226
Second Schedule A, Part V, Line 26
(15)
Indicator field for results of MeF check of VIN against portal
312IN
N/A
(16)
Verified field for SUM-REDCD-VIN-CR-VERIFIED-AMT
31RDV
N/A
(17)
Indicator (More than 2 Schedule A’s attached)
313IN
Second Form 8936, Schedule A, (edited bottom right margin of Page 2).
Form 990-T - Section 35, Form 4255¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Form 7207 Recapture Net EPE Amount
1AS$
Enter Part 1, Line 1a, Column s.
(3)
Form 7207 Excessive Payment Amount
1AT$
Enter Part 1, Line 1a, Column t.
(4)
Form 3468, Part III Recapture Net EPE Amount
1BS$
Enter Part 1, Line 1b, Column s.
(5)
Form 3468, Part III Excessive Payment Amount
1BT$
Enter Part 1, Line 1b, Column t.
(6)
Form 7210 Recapture Net EPE Amount
1CS$
Enter Part 1, Line 1c, Column s.
(7)
Form 7210 Excessive Payment Amount
1CT$
Enter Part 1, Line 1c, Column t.
(8)
Form 3468, Part IV Recapture Net EPE Amount
1DS$
Enter Part 1, Line 1d, Column s.
(9)
Form 3468, Part IV Excessive Payment Amount
1DT$
Enter Part 1, Line 1d, Column t.
(10)
Form 7218 Recapture Net EPE Amount
1ES$
Enter Part 1, Line 1e, Column s.
(11)
Form 7218 Excessive Payment Amount
1ET$
Enter Part 1, Line 1e, Column t.
(12)
Form 7213 Recapture Net EPE Amount
1FS$
Enter Part 1, Line 1f, Column s.
(13)
Form 7213 Excessive Payment Amount
1FT$
Enter Part 1, Line 1f, Column t.
(14)
Form 3468, Part V Recapture Net EPE Amount
1GS$
Enter Part 1, Line 1g, Column s.
(15)
Form 3468, Part V Excessive Payment Amount
1GT$
Enter Part 1, Line 1g, Column t.
(16)
Form 8936, Part V Recapture Net EPE Amount
1HS$
Enter Part 1, Line 1h, Column s.
(17)
Form 8936, Part V Excessive Payment Amount
1HT$
<ENTER
Enter Part i, Line 1h, Column t.
(18)
Form 7211 Recapture Net EPE Amount
1IS$
Enter Part 1, Line 1i, Column s.
(19)
Form 7211 Excessive Payment Amount
1IT$
Enter Part 1, Line 1i, Column t.
(20)
Form 3468, Part VI Recapture Net EPE Amount
1JS$
Enter Part 1, Line 1j, Column s.
(21)
Form 3468, Part IV Excessive Payment Amount
1JT$
Enter Part 1, Line 1j, Column t.
(22)
Form 8835 Recapture Net EPE Amount
1KS$
Enter Part 1, Line 1k, Column s.
(23)
Form 8835 Excessive Payment Amount
1KT$
Enter Part 1, Line 1k, Column t.
(24)
Form 8933 Recapture Net EPE Amount
2AS$
Enter Part 1, Line 2a, Column s.
(25)
Form 8933 Excessive Payment Amount
2AT$
Enter Part 1, Line 2a, Column t.
(26)
Form 8911, Part I Recapture Net EPE Amount
2BS$
Enter Part 1, Line 2b, Column s.
(27)
Form 8911, Part I Excessive Payment Amount
2BT$
Enter Part 1, Line 2b, Column t.
Form 990-T - Section 60, Form 8050¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT
Press
(2)
Routing Transit Number
60RTN
Enter the routing number from F8050, line1.
(3)
Deposit Account Number
60DAN
Enter the account number from F8050, line 2.
(4)
Type of Deposit
C = Checking
S = Savings
60TDA
Enter the type of account, F8080, line 3, checkbox.
C = Checking
S = Savings
Form 1041-A - Section 01¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4
(3a)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4
(4)
Employer Identification Number
EIN
Enter the EIN from the preprinted label or from EIN block.
See standard rules in IRM 3.24.38.
For error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4.1
(5)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
(6)
Condition Codes
CC
Enter the edited characters as shown below the OMB Number.
If a condition code is illegible, enter a "#" in its place.
(7)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
If a "G" Condition Code is present and return is a non-remittance, end the document after this element.
If a "G" Condition Code is present and return is a remittance, press
See IRM 3.24.38 for special instructions.
(8)
P & I Indicator
P&I
Enter the edited digit shown to the right of the EIN.
(9)
Correspondence Code
CORC
Enter the 2 edited digits shown to the right of the City and State.
(10)
Correspondence Received Date
CRD
Enter the edited digits shown to the right of the Correspondence Code. Example: 11–020600.
For special instructions, see IRM 3.24.38.
(11)
Daily Delinquency Penalty
DDP
Enter the edited amount shown to the right of Part II title.
(12)
ERS Action Code
ERS
Enter the edited digits from the bottom left margin.
(13)
CAF Indicator
CAF
Enter the edited digit from the bottom right margin.
(14)
Preparation Code
PREP
Enter the edited code from the right of the preparer PTIN line.
(15)
Preparer's PTIN
PTIN
Enter the Preparer's PTIN.
(16)
Preparer's EIN
PEIN
Enter the Preparer's EIN.
(17)
Preparer's Telephone
PTEL
Enter the Preparer's phone number.
Form 1041-A - Section 03¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance Amount
RMT
Enter the edited amount shown in the top center margin of the return.
Check the control document (Form 813) for the correct amount in case of illegibility.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Total Income
LN9 $
Enter the amount from Part I, Line 9.
(4)
Total Assets (BOY)
38(A) $
Enter the amount from Part IV, Line 38, Column (a).
(5)
Total Assets (EOY)
38(B) $
Enter the amount from Part IV, Line 38, Column (b).
(6)
Total Liabilities (BOY)
42(A) $
Enter the amount from Part IV, Line 42, Column (a).
(7)
Total Liabilities (EOY)
42(B) $
Enter the amount from Part IV, Line 42, Column (b).
(8)
Total Net Assets (BOY)
45(A) $
Enter the amount from Part IV, Line 45, Column (a).
(9)
Total Net Assets (EOY)
45(B) $
Enter the amount from Part IV, Line 45, Column (b).
(10)
Total Liabilities and Net Assets (BOY)
46(A) $
Enter the amount from Part IV, Line 46, Column (a).
(11)
Total Liabilities and Net Assets (EOY)
46(B) $
Enter the amount from Part IV, Line 46, Column (b).
Form 1120–POL - Section 01¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Section "01" always generates. No entry required.
(2)
Serial Number
SER#
Enter the last two digits of the 13–digit DLN from the upper portion of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4
(3a)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4
(4)
Employer Identification Number
EIN
Enter the EIN from the preprinted label or from EIN block.
See standard rules in IRM 3.24.38.
For error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4
(5)
Address Check
ADDRESS CHECK?
ENTER "Y" or "N" as appropriate.
(6)
Street Key
STREET KEY
See IRM 3.24.38
(7)
ZIP Key
ZIP KEY
See IRM 3.24.38
(8)
Tax Period
TAXPR
Enter in YYMM format the tax period edited to the right of, or underlined under, the form title.
If not edited or underlined, press
For standard instructions, see IRM 3.24.38.
(9)
In Care of Name Line
C/O NAME
Enter the in care of name, if shown.
Note:¶
Downstream processing generates the (%) sign.
(10)
Foreign Address
FGN ADD
Enter the Foreign address, if shown.
See IRM 3.24.38 for additional instruction.
(11)
Street Address
ADD
Enter the street address from the address line.
If a "G" Condition Code is present, do NOT enter any of the address information even if prompted. This occurs when a Name Control is entered.
If a foreign address, enter the foreign city, province and postal code.
See IRM 3.24.28 for specific instructions.
(12)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(13)
State
ST
Enter the standard state abbreviation from the city/state line. .
If a Major City Code was entered, press
If a foreign address, enter a period (.).
See IRM 3.24.38.
(14)
ZIP
ZIP
Enter the ZIP Code.
If a foreign address, press
(15)
Received Date
RDATE
Enter as stamped on the face of the return or edited on the dotted portion of Line 11, in MMDDYY format.
For standard instructions, see IRM 3.24.38.
(16)
Condition Codes
CC
Enter as shown on the dotted portion of Line 1.
If a Condition Code is illegible, enter a "#" .
(17)
Return Processing Code
01RPC
For 2018 and subsequent tax periods enter the edited codes on Page 1, in the right margin next to line 1.
(18)
Tax Period Beginning
YRBEGDT
Enter the tax period Beginning in MMDDYY format when edited to the left of form title area at the top of the form.
(18)
Principal Campaign Committee
PCC
Enter the edited 1, 2, or 3 from the right of "Candidates for U.S. Congress Only" line.
For 2018 and subsequent, enter only.
(19)
ERS Action Code
ACTCD
Enter the edited digits from the bottom left margin.
If a "G" Condition Code is present or if the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If a "G" Condition Code is present or if the ERS Action Code is in the "600" series and the return is a remittance, Press
If no additional data for this or any other sections, end the document.
(20)
EOMF Code
EOMF
Enter the edited "1" shown in the right margin next to the Tax Year.
(21)
Filling Field (VIN Portal Information Field)
N/A
N/A
Form 1120–POL - Section 02, Form 5800 - Edit Sheet¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(2)
Audit Code
L2
Enter from Edit Sheet, Line 2.
(3)
CAF Indicator/Code
L3
Enter from Edit Sheet, Line 3.
(4)
Correspondence Received Date
L5
Enter from Edit Sheet, Line 5, in MMDDYY format. (a)
For standard instructions, see IRM 3.24.38.
(5)
Penalty and Interest Code
L6
Enter from Edit Sheet, Line 6.
(6)
Missing Schedule Code
L8
Enter from Edit Sheet, Line 8.
Form 1120–POL - Section 03¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(2)
Payment Received
RMT
Enter the green edited amount shown on Line 25.
If a green edited amount isn't present, enter the amount written in green, or the cash register imprint amount shown in the upper right margin.
Check the control document (Form 813, Form 3893) for correct amount in case of illegibility.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
If the ERS Action Code is in the "600" series, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Dividends
L1 $
Enter the amount from Line 1.
(4)
Taxable Interest
L2 $
Enter the amount from Line 2.
(5)
Gross Rents
L3 $
Enter the amount from Line 3.
(6)
Gross Royalties
L4 $
Enter the amount from Line 4.
(7)
Capital Gain
L5 $
Enter the amount from Line 5.
(8)
Ordinary Gain or Loss
L6 $
Enter the amount from Line 6.
(9)
Other Income
L7 $
Enter the amount from Line 7.
(10)
Gross Income
L8
Enter the amount from Line 8.
Form 1120–POL - Section 04¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(2)
Salaries and Wages Deduction
L9 $
Enter the amount from Line 9.
(3)
Repairs Deduction
10 $
Enter the amount from Line 10.
(4)
Rent Deduction
11 $
Enter the amount from Line 11.
(5)
Tax Deduction
12 $
Enter the amount from Line 12.
(6)
Interest Deduction
13 $
Enter the amount from Line 13.
(7)
Depreciation Deduction
14 $
Enter the amount from Line 14.
(8)
Other Deduction
15 $
Enter the amount from Line 15.
(9)
Total Deductions
16
Enter the amount from Line 16.
(10)
Specific Deductions
18 $
Enter the amount from Line 18.
(11)
Statutory Credits
21
Enter the amount from Line 21.
Form 1120–POL - Section 05¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(2)
Foreign Tax Credit
21A
Enter the amount from line 21a.
(3)
Other Credit
21B
Enter the amount from line 21b.
(4)
General Business Credit
21C
Enter the amount from line 21c.
(5)
Total Tax Credits
21D
Enter the amount from line 21d.
(6)
Total Tax
22
Enter the amount from Line 22.
(7)
Total Overpayment and Estimated Tax Credits
22...
Enter the amount from the dotted portion of Line 22.
(8)
Form 7004 Credits
23A
Enter the amount from Line 23a.
(9)
Credit From Undistributed Capital Gains (2439)
23B
Enter the amount from Line 23b.
(10)
Federal Telephone Excise Tax Paid
23SPACE
Enter the amount from the space to the right of Line 23c.
(11)
Elective payment Election
23D $
Enter the amount from Line 23d
(12)
Balance Due/Overpayment
24/25
Enter the amount as follows:
From Line 24, followed by
If no amount Line 24, enter the amount from Line 25, with a MINUS (−).
If there are entries on both lines, enter the amount from Line 24.
(13)
Discuss with Preparer Checkbox
CKBX
Enter a "1" if the "Yes" box is checked.
Otherwise, press
(14)
Preparer's PTIN
PTIN
Enter the Preparer's PTIN.
(15)
Preparer's EIN
PEIN
Enter the Preparer's EIN.
(16)
Preparer's Telephone Number
TEL#
Enter the Preparer's phone number.
Form 1120-POL - Section 15, Form 4136¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Amount of Claim 1
AMT1(D)
Enter the first amount shown on Column (d).
(3)
Credit Reference Number 1
CRN1(E)
Enter the CRN from Column (e) that correspond with the first amount entered.
(4)
Amount of Claim 2
AMT2(D)
Enter the second amount shown on Column (d).
(5)
Credit Reference Number 2
CRN2(E)
Enter the CRN from Column (e) that corresponds with the second amount entered.
(6)
Amount of Claim 3
AMT3(D)
Enter the third amount shown on Column (d).
(7)
Credit Reference Number 3
CRN3(E)
Enter the CRN from Column (e) that corresponds with the third amount entered.
(8)
Amount of Claim 4
AMT4(D)
Enter the fourth amount shown on Column (d).
(9)
Credit Reference Number 4
CRN4(E)
Enter the CRN from Column (e) that corresponds with the fourth amount entered.
(10)
Amount of Claim 5
AMT5(D)
Enter the fifth amount shown on Column (d).
(11)
Credit Reference Number 5
CRN5(E)
Enter the CRN from Column (e) that corresponds with the fifth amount entered.
(12)
Amount of Claim 6
AMT6(D)
Enter the sixth amount shown on Column (d).
(13)
Credit Reference Number 6
CRN6(E)
Enter the CRN from Column (e) that corresponds with the sixth amount entered.
(14)
Amount of Claim 7
AMT7(D)
Enter the seventh amount shown on Column (d).
(15)
Credit Reference Number 7
CRN7(E)
Enter the CRN from Column (e) that corresponds with the seventh amount entered.
(16)
Amount of Claim 8
AMT8(D)
Enter the eighth amount shown on Column (d).
(17)
Credit Reference Number 8
CRN8(E)
Enter the CRN from Column (e) that corresponds with the eighth amount entered.
(18)
Amount of Claim 9
AMT9(D)
Enter the ninth amount shown on Column (d).
(19)
Credit Reference Number 9
CRN9(E)
Enter the CRN from Column (e) that corresponds with the ninth amount entered.
(20)
Amount of Claim 10
AMT10(D)
Enter the tenth amount shown on Column (d).
(21)
Credit Reference Number 10
CRN10(E)
Enter the CRN from Column (e) that corresponds with the tenth amount entered.
(22)
Amount of Claim 11
AMT11(D)
Enter the eleventh amount shown on Column (d).
(23)
Credit Reference Number 11
CRN11(E)
Enter the CRN from Column (e) that corresponds with the eleventh amount entered.
(24)
Amount of Claim 12
AMT12(D)
Enter the twelfth amount shown on Column (d).
(25)
Credit Reference Number 12
CRN12(E)
Enter the CRN from Column (e) that corresponds with the twelfth amount entered.
(26)
Amount of Claim 13
AMT13(D)
Enter the thirteenth amount shown on Column (d).
(27)
Credit Reference Number 13
CRN13(E)
Enter the CRN from Column (e) that corresponds with the thirteenth amount entered.
(28)
Amount of Claim 14
AMT14(D)
Enter the fourteenth amount shown on Column (d).
(29)
Credit Reference Number 14
CRN14(E)
Enter the CRN from Column (e) that corresponds with the fourteenth amount entered.
(30)
Amount of Claim 15
AMT15(D)
Enter the fifteenth amount shown on Column (d).
(31)
Credit Reference Number 15
CRN15(E)
Enter the CRN from Column (e) that corresponds with the fifteenth amount entered.
(32)
Amount of Claim 16
AMT16(D)
Enter the sixteenth amount shown on Column (d).
(33)
Credit Reference Number 16
CRN16(E)
Enter the CRN from Column (e) that corresponds with the sixteenth amount entered.
(34)
Amount of Claim 17
AMT17(D)
Enter the seventeenth amount shown on Column (d).
(35)
Credit Reference Number 17
CRN17(E)
Enter the CRN from Column (e) that corresponds with the seventeenth amount entered.
(36)
Amount of Claim 18
AMT18(D)
Enter the eighteenth amount shown on Column (d).
(37)
Credit Reference Number 18
CRN18(E)
Enter the CRN from Column (e) that corresponds with the eighteenth amount entered.
(38)
Amount of Claim 19
AMT19(D)
Enter the nineteenth amount shown on Column (d).
(39)
Credit Reference Number 19
CRN19(E)
Enter the CRN from Column (e) that corresponds with the nineteenth amount entered.
(40)
Amount of Claim 20
AMT20(D)
Enter the twentieth amount shown on Column (d).
(41)
Credit Reference Number 20
CRN20(E)
Enter the CRN from Column (e) that corresponds with the twentieth amount entered.
Form 1120-POL - Section 19, Form 8978¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Source of Review Year Adjustments
CKBX
Enter "1" if BBA Audit is checked. Enter "2" if AAR filing is checked.
(3)
Total Additional Reporting Year Tax
L14
Enter the amount from Part I, Line 14.
(4)
Total Penalties
L16
Enter the amount from Part II, Line 16.
(5)
Total Interest
L18
Enter the amount from Part III, Line 18.
Form 1120-POL - Section 20, Form 8913¶
Elem.
Data Element Name
Prompt
Fld. Term
Instructions
(1)
Section Number
SECT:
Press ENTER if already present on the screen, otherwise enter "20" .
(2)
Tax Refund
15D
Enter the amount from Line 15d.
(3)
Interest on Tax Refund
15E
Enter the amount from Line 15e.
Form 1120-POL - Section 23, Form 3800¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Form 7207 Registration Number 1B
1BB
Enter the number from Part III, Line 1b, Column b.
(3)
Form 7207 Credit Transfer Election Amount 1B
1BF$
<ENTER +/->
Enter the amount from Part III, Line 1b, Column f.
(4)
Form 7207 Credit Allowed After Passive Activity Limit
1BG$
Enter the amount from Part III, Line 1b, Column g.
(5)
Form 7207 Gross Elective Payment Election Amount 1B
1BH$
Enter the amount from Part III, Line 1b, Column h.
(6)
Form 7207 Net Elective Payment Electron Amount Line 1B Total
1BIJ$
Enter the amount from Part III, Line 1b, Column j.
(7)
Form 3468 Registration Number 1D
1DB
Enter the number from Part III, Line 1d, Column b.
(8)
Form 3468 Credit Transfer Election Amount 1D
1DF$
<ENTER +/->
Enter the amount from Part III, Line 1d, Column f.
(9)
Form 3468 Credit Allowed After Passive Activity Limit
1DG$
Enter the amount from Part III, Line 1d, Column g.
(10)
Form 3468 Gross Elective Payment Election 1D
1DH$
Enter the amount from Part III, Line 1d, Column h.
(11)
Form 3468 Net Elective Payment Election Credit Amount 1D
1DJ$
Enter the amount from Part III, Line 1d, Column j.
(12)
Form 8835, Part II Registration Number 1F
1FB
Enter the number from Part III, Line 1f, Column b.
(13)
Form 8835 , Part II Credit Transfer Election Amount 1F
1FF$
<ENTER +/->
Enter the amount from Part III, Line 1f, Column f.
(14)
Form 8835, Part II Credit Allowed After Passive Activity Limit
1FG$
Enter the amount from Part III, Line 1f, Column g.
(15)
Form 7210 Registration Number 1G
1GB
Enter the number from Part III, Line 1g, Column b.
(16)
Form 7210 Credit Transfer Election Amount 1G
1GF$
<ENTER +/->
Enter the amount from Part III, Line 1g, Column f.
(17)
Form 7210 Credit Allowed After Passive Activity Limit
1GG$
Enter the amount from Part III, Line 1g, Column g.
(18)
Form 7210 Gross Elective Payment Election 1G
1GH$
Enter the amount from Part III, Line 1g, Column h.
(19)
Form 7210 Net Elective Payment Election Credit Amount 1G
1GJ$
Enter the amount from Part III, Line 1g, Column j.
Form 1120-POL - Section 24, Form 3800¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Form 3468 , Part IV Registration Number 1O
1OB
Enter the number from Part III, Line 1o, Column b.
(3)
Form 3468, Part IV Credit Allowed After Passive Activity Limit
1OG$
Enter the number from Part III, Line 1o, Column g.
(4)
Form 3468, Part IV Gross Elective Payment Election 1O
1OH$
Enter the number from Part III, Line 1o, Column h.
(5)
Form 3468, Part IV Net Elective Payment Election Credit Amount 1O
1OJ$
Enter the number from Part III, Line 1o, Column j.
(6)
Form 7218 Registration Number
1QB
Part III, Line 1q, Column b.
(7)
Form 7218 Credit Transfer Election Amount
1QF$
<ENTER +/->
Part III, Line 1q, Column f.
(8)
Form 7218 Credit Allowed After Passive Activity Limit
1QG$
Part III, Line 1q, Column g.
(9)
Form 7218 Gross Elective Payment Election
1QH$
Part III, Line 1q, Column h.
(10)
Form 7218 Net Elective Payment Election Credit Amount
1QJ$
Part III, Line 1q, Column j.
(11)
Form 8911 Registration Number 1S
1SB
Enter the number from Part III, Line 1s, Column b.
(12)
Form 8911 Credit Transfer Election Amount 1S
1SF$
<ENTER +/->
Enter the amount from Part III, Line 1s, Column f.
(13)
Form 8911 Credit Allowed After Passive Activity Limit
1SG$
Enter the amount from Part III, Line 1s, Column g.
(14)
Form 8911 Gross Elective Payment Election 1S
1SH$
Enter the amount from Part III, Line 1s, Column h.
(15)
Form 8911 Net Elective Payment Election Credit Amount 1S
1SJ$
Enter the amount from Part III, Line 1s, Column j.
(16)
Form 7213, Part II Registration Number 1U
1UB
Enter the number from Part III, Line 1u, Column b.
(17)
Form 7213 , Part II Credit Transfer Election Amount 1U
1UF$
<ENTER +/->
Enter the amount from Part III, Line 1u, Column f.
(18)
Form 7213, Part II Credit Allowed After Passive Activity Limit
1UG$
Enter the amount from Part III, Line 1u, Column g.
(19)
Form 7213, Part II Gross Payment Election 1U
1UH$
Enter the amount from Part III, Line 1u, Column h.
(20)
Form 7213, Part II Net Elective Payment Election Credit Amount 1U
1UJ$
Enter the amount from Part III, Line 1u, Column j.
(21)
Form 3468, Part V Registration Number 1X
1VB
Enter the number from Part III, Line 1v, Column b.
(22)
Form 3468, Part V Credit Transfer Election Amount 1V
1VF$
<ENTER +/->
Enter the number from Part III, Line 1v, Column f.
(23)
Form 3468, Part V Credit Allowed After Passive Activity Limit 1V
1VG$
Enter the number from Part III, Line 1v, Column g.
(24)
Form 3468, Part V Gross Elective Payment Election 1V
1VH$
Enter the number from Part III, Line 1v, Column h.
(25)
Form 3468, Part V Net Elective Payment Election Credit Amount 1V
1VJ$
Enter the number from Part III, Line 1v, Column j.
(26)
Form 8933 Registration Number 1X
1XB
Enter the number from Part III, Line 1x, Column b.
(27)
Form 8933 Credit Transfer Election Amount 1X
1XF$
<ENTER +/->
Enter the amount from Part III, Line 1x, Column f.
(28)
Form 8933 Credit Allowed After Passive Activity Limit 1X
1XG$
Enter the amount from Part III, Line 1x, Column g.
(29)
Form 8933 Gross Elective Payment Election 1X
1XH$
Enter the amount from Part III, Line 1x, Column h.
(30)
Form 8933 Net Elective Payment Election Credit Amount 1X
1XJ$
Enter the amount from Part III, Line 1x, Column j.
Form 1120-POL - Section 25, Form 3800¶
Elem.
Data Element Name
Prompt
Fld. Term,
Instructions
(1)
Section Number
SECT:
Press
(2)
Form 8936 , Part V Registration Number 1AA
1AAB
Enter the number from Part III, Line 1aa, Column b.
(3)
Form 8936, Part V Credit Allowed After Passive Activity Limit
1AAG
Enter the amount from Part III, Line 1aa, Column g.
(4)
Form 8936, Part V Gross Elective Payment Election 1AA
1AAH$
Enter the amount from Part III, Line 1aa, Column h.
(5)
Form 8936, Part V Net Elective Payment Election Credit Amount 1AA
1AAJI$
Enter the amount from Part III, Line 1aa, Column j.
(6)
Form 7211, Reserved Number
1GGB
Part III, Line 1gg Column b.
(7)
Form 7211, Credit Transfer Election Amount
1GGF
<ENTER +/->
Part III, LIne 1gg Column f.
(8)
Form 7211, Credit Allowed After Passive Activity Limit
1GG$
Part III, LIne 1gg Column g.
(9)
Form 7211, Gross Elective Payment Election
1GGH$
Part III, Line 1gg Column h.
(10)
Form 7211, Net Elective Payment Election Amount
1GGJI$
Part III, Line 1gg Column j.
(11)
Form 3468, Part VI Registration Number 4A
4AB
Enter the number from Part III, Line 4a, Column b.
(12)
Form 3468 , Part IV Credit Transfer Election Amount 4A
4AF$
<ENTER +/->
Enter the amount from Part III, Line 4a, Column f.
(13)
Form 3468, Part VI Credit Allowed After Passive Activity Limit
4AG$
Enter the amount from Part III, Line 4a, Column g.
(14)
Form 3468, Part VI Gross Elective Payment Election 4A
4AH$
Enter the amount from Part III, Line 4a, Column h.
(15)
Form 3468, Part VI Net Elective Payment Election Credit Amount 4A
4AJ$
Enter the amount from Part III, Line 4a, Column j.
(16)
Form 8835, Part II Registration Number 4E
4EB
Enter the number from Part III, Line 4e, Column b.
(17)
Form 8835 , Part II Credit Transfer Election Amount 4E
AEF$
<ENTER +/->
Enter the amount from Part III, Line 4e, Column f.
(18)
Form 8835, Part II Credit Allowed After Passive Activity Limit
AEG$
Enter the amount from Part III, Line 4e, Column g.
(19)
Form 8835, Part II Gross Elective Payment Election 4E
AEH$
Enter the amount from Part III, Line 4e, Column h.
(20)
Form 8835, Part II Net Elective Payment Election Credit Amount 4E
AEJ$
Enter the amount from Part III, Line 4e, Column j.
(21)
Part V indicator
VIND
Enter 1 if any Box in Part V, column b is marked.
Form 1120-POL - Section 31, Form 3800¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Vehicle Identification Number (VIN)
311VI
First Schedule A, Part I, Line 2
(3)
Placed in service date
311DT
First Schedule A, Part I, Line 3
(4)
Tentative credit amount
31109
First Schedule A, Part II, Line 9
(5)
Credit amount for business use of new clean vehicle
31111
Part II, Line 11
(6)
Smaller of Line 15 or Line 16
31117
First Schedule A, Part IV, Line 17
(7)
Smaller of Line 24 or Line 25
31126
First Schedule A, Part V, Line 26
(8)
Indicator field for results of MeF check of VIN against portal
311IN
N/A
(9)
Vehicle Identification Number (VIN)
312VI
Second Schedule A, Part I, Line 2
(10)
Placed in service date
312DT
Second Schedule A, Part I, Line 3
(11)
Tentative credit amount
31209
Second Schedule A, Part II, Line 9
(12)
Credit amount for business use of new clean vehicle
31211
Part II, Line 11
(13)
Smaller of Line 15 or Line 16
31217
Second Schedule A, Part IV, Line 17
(14)
Smaller of Line 24 or Line 25
31226
Second Schedule A, Part V, Line 26
(15)
Indicator field for results of MeF check of VIN against portal
312IN
N/A
(16)
Indicator (More than 2 Schedule A’s attached)
313IN
Second Form 8936, Schedule A, (edited bottom right margin of Page 2).
Form 1120-POL - Section 35, Form 4255¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Form 7207 Recapture Net EPE Amount
1AS$
Enter Part 1, Line 1a, Column s.
(3)
Form 7207 Excessive Payment Amount
1AT$
Enter Part 1, Line 1a, Column t.
(4)
Form 3468, Part III Recapture Net EPE Amount
1BS$
Enter Part 1, Line 1b, Column s.
(5)
Form 3468, Part III Excessive Payment Amount
1BT$
Enter Part 1, Line 1b, Column t.
(6)
Form 7210 Recapture Net EPE Amount
1CS$
Enter Part 1, Line 1c, Column s.
(7)
Form 7210 Excessive Payment Amount
1CT$
Enter Part 1, Line 1c, Column t.
(8)
Form 3468, Part IV Recapture Net EPE Amount
1DS$
Enter Part 1, Line 1d, Column s.
(9)
Form 3468, Part IV Excessive Payment Amount
1DT$
Enter Part 1, Line 1d, Column t.
(10)
Form 7218 Recapture Net EPE Amount
1ES$
Enter Part 1, Line 1e, Column s.
(11)
Form 7218 Excessive Payment Amount
1ET$
Enter Part 1, Line 1e, Column t.
(12)
Form 7213 Recapture Net EPE Amount
1FS$
Enter Part 1, Line 1f, Column s.
(13)
Form 7213 Excessive Payment Amount
1FT$
Enter Part 1, Line 1f, Column t.
(14)
Form 3468, Part V Recapture Net EPE Amount
1GS$
Enter Part 1, Line 1g, Column s.
(15)
Form 3468, Part V Excessive Payment Amount
1GT$
Enter Part 1, Line 1g, Column t.
(16)
Form 8936, Part V Recapture Net EPE Amount
1HS$
Enter Part 1, Line 1h, Column s.
(17)
Form 8936, Part V Excessive Payment Amount
1HT$
<ENTER
Enter Part i, Line 1h, Column t.
(18)
Form 7211 Recapture Net EPE Amount
1IS$
Enter Part 1, Line 1i, Column s.
(19)
Form 7211 Excessive Payment Amount
1IT$
Enter Part 1, Line 1i, Column t.
(20)
Form 3468, Part VI Recapture Net EPE Amount
1JS$
Enter Part 1, Line 1j, Column s.
(21)
Form 3468, Part IV Excessive Payment Amount
1JT$
Enter Part 1, Line 1j, Column t.
(22)
Form 8835 Recapture Net EPE Amount
1KS$
Enter Part 1, Line 1k, Column s.
(23)
Form 8835 Excessive Payment Amount
1KT$
Enter Part 1, Line 1k, Column t.
(24)
Form 8933 Recapture Net EPE Amount
2AS$
Enter Part 1, Line 2a, Column s.
(25)
Form 8933 Excessive Payment Amount
2AT$
Enter Part 1, Line 2a, Column t.
(26)
Form 8911, Part I Recapture Net EPE Amount
2BS$
Enter Part 1, Line 2b, Column s.
(27)
Form 8911, Part I Excessive Payment Amount
2BT$
Enter Part 1, Line 2b, Column t.
Form 1120-POL - Section 60, Form 8050¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT
Press
(2)
Routing Transit Number
60RTN
Enter the routing number from F8050, line1.
(3)
Deposit Account Number
60DAN
Enter the account number from F8050, line 2.
(4)
Type of Deposit
C = Checking
S = Savings
60TDA
Enter the type of account, F8080, line 3, checkbox.
C = Checking
S = Savings
Form 4720 - Section 01¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3a)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4
(3a)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4
(4)
Employer Identification Number
EIN
Enter the EIN from the preprinted label or from EIN block.
See standard rules in IRM 3.24.38.
For error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4
(5)
TIN Type
TIN
Enter the edited 0 or 2 following the TIN.
(6)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
(7)
Condition Codes
CC
Enter the edited characters as shown to the right of the printed year.
If a condition code is illegible, enter a "#" in its place.
(8)
Received Date
DATE
Enter the six digits for the received date in MMDDYY format from the face of the return.
If a "G" Condition Code is present and return is a non-remittance, end the document after this element.
If a "G" Condition Code is present and return is a remittance, press
See IRM 3.24.38 for special instructions.
(9)
Type Organization Code
TYPE
Enter the edited digit from the Type of Annual Return box.
(10)
Audit Indicator
A…
Enter the edited digit shown on the dotted portion of Line A.
(11)
Question A
A RT
Enter a Yes or No from the yes/no box from Line A.
(12)
Question B
B RT
Enter a Yes or No from the yes/no box from Line B.
(13)
CAF Indicator
B…
Enter the edited digit shown on the dotted portion of Line B.
(14)
Correspondence Code
1…
Enter the edited digits shown on the dotted portion of Line 1.
(15)
Correspondence Received Date
2…
Enter the edited digits shown on the dotted portion of Line 2.
For special instructions, see IRM 3.24.38.
(16)
Penalty and Interest Code
3…
Enter the edited digit shown on the dotted portion of Line 3.
(17)
ERS Action Codes
BOTLFMAR
Enter the edited ERS Action Code.
(18)
Signature Code
01SIG
Enter a "1" if the signature is present and "2" if it is not signed.
Form 4720 - Section 02¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Tax on Undistributed Income
LN1
Enter the amount from Part I, Line 1.
(3)
Tax on Excess Business Holding
LN2
Enter the amount from Part I, Line 2.
(4)
Tax on Investments that Jeopardize
LN3
Enter the amount from Part I, Line 3.
(5)
Tax on Taxable Expenditures
LN4
Enter the amount from Part I, Line 4.
(6)
Tax on Political Expenditures
LN5
Enter the amount from Part I, Line 5.
(7)
Tax on Excess Lob Expenditures
LN6
Enter the amount from Part I, Line 6.
(8)
Tax on Disqualifying Lobbying Expenditures
LN7
Enter the amount from Part I, Line 7.
(9)
Tax on Premiums Paid.. Contracts
LN8
Enter the amount from Part I, Line 8.
(10)
Tax on Entering Prohibited Tax Shelter Transactions
LN9
Enter the amount from Part I, Line 9.
(11)
Tax on Taxable Distributions
L10
Enter the amount from Part I, Line 10.
(12)
Tax on Unrelated Business Taxable Income
L11
Enter the amount from Part I, Line 11.
(13)
Tax on Failure to Meet Requirements of 501(r)(3)
L12
Enter the amount from Part I, Line 12.
(14)
Tax on Excess Executive Compensation
L13
Enter the amount from Part I, Line 13.
(15)
Tax on Private Colleges and Universities
L14
Enter the amount from Part I, Line 14.
(16)
Total Tax Part I
L15
Enter the amount from Part I, Line 15.
(17)
Organization EIN
(B) EIN
Enter the EIN from Part II Column (b)
(18)
Tax on Self-Dealing Part II, Line 1
(1) T
Enter the amount from Part II, Line 1.
(19)
Tax on Investments that Jeopardize Part II, Line 2
(2) T
Enter the amount from Part II, Line 2.
(20)
Tax on Taxable Expenditures Part II, Line 3
(3) T
Enter the amount from Part II, Line 3.
(21)
Tax on Political Expenditures Part II, Line 4
(4) T
Enter the amount from Part II, Line 4.
(22)
Tax on Disqualifying Lobbying Expenditures Part II, Line 5
(5) T
Enter the amount from Part II, Line 5.
(23)
Tax on Excess Benefits Part II, Line 6
(6) T
Enter the amount from Part II, Line 6.
(24)
Tax on Prohibited Tax Shelter Transactions Part II, Line 7
(7) T
Enter the amount from Part II, Line 7.
(25)
Tax on Taxable Distributions Part II, Line 8
(8) T
Enter the amount from Part II, Line 8.
(26)
Tax on Prohibited Benefits Part II, Line 9
(9) T
Enter the amount from Part II, Line 9.
(27)
Total Tax Part II, Line 10
(10) T
Enter the amount from Part II, Line 10.
(28)
Total Tax
PTIII1
Enter the amount from Part III, Line 1.
(29)
Total Payments
PTIII2
Enter the amount from Part III, Line 2.
op(30)
Tax Due/Overpayment
PTIII3
Enter the amount from Part III, Line 3 or 4.
(31)
Excess Grass Roots Expenditures
SCHG–1
Enter the amount from Schedule G, Line 1.
(32)
Excess Lobbying Expenditures
G–2
Enter the amount from Schedule G, Line 2.
(33)
Lobby Expenditures Tax
G–4
Enter the amount from Schedule G, Line 4.
(34)
Preparation Code
PREP
Enter the edited code from the right of the Preparer PTIN line.
(35)
Preparer's PTIN
PTIN
Enter the Preparer's PTIN.
(36)
Preparer's EIN
PEIN
Enter the Preparer's EIN from the Preparer's EIN box.
(37)
Preparer's Telephone Number
TEL#
Enter the Preparer's phone number from the Preparer's phone number box.
Form 4720 - Section 03¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance Amount
RMT
Enter the edited amount shown in the top center margin of the return.
Check the control document (Form 813) for the correct amount in case of illegibility.
Press
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
Form 4720 - Section 60, Form 8050¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT
Press
(2)
Routing Transit Number
60RTN
Enter the routing number from F8050, line1.
(3)
Deposit Account Number
60DAN
Enter the account number from F8050, line 2.
(4)
Type of Deposit
C = Checking
S = Savings
60TDA
Enter the type of account, F8080, line 3, checkbox.
C = Checking
S = Savings
Form 5227 - Section 01¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(auto)
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4
(5)
Employer Identification Number
EIN
Enter the EIN from the preprinted label or from EIN block.
See standard rules in IRM 3.24.38.
For error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4
(6)
Address Check
ADDRESS CHECK?
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY
See IRM 3.24.38.
(8)
ZIP Key
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
(10)
Computer Condition Codes
CCC
Enter the code(s) from the center portion of the return below the entity section. If a condition code is illegible, enter a "#" in its place.
(11)
Received Date
RDATE
Enter the stamped or edited date in MMDDYY format from the face of the return.
If a "G" Condition Code is present and the return is a non-remittance, end the document after this element.
See IRM 3.24.38 for special instructions.
(12)
Type of Organization Code
ORGCD
Enter the number that correlates with the box 1-5 checked from the Type of Entity box marked in Item C of the entity area.
Example:¶
If Box (1) is checked, you would enter a "1" . If Box (5) is checked you would enter a "5" . If more than one box is checked or no box is checked, enter either the edited digit or a "2" as a default.
(13)
In Care of Name Line
C/O NAME
Enter the care of name, if shown.
Note:¶
Downstream processing generates a (%) sign.
(14)
Foreign Address
FGN ADD
Enter the foreign street address, if shown.
See IRM 3.24.38 for additional instructions.
(15)
Street Address
ADDR
Enter the street address from the address line.
If a foreign address, enter the foreign city, province and postal code.
If a "G" Condition Code is present on the return, do NOT enter any of the address information even if prompted. This occurs when a Name Control is entered.
See IRM 3.24.38 for specific instructions.
(16)
City
CITY
Enter the city name from the city line or Major City Code, if appropriate.
If a foreign address, enter the edited foreign country's code.
(17)
State
ST
Enter the standard state abbreviation from the city/state line.
If a Major City Code was entered, press
If a foreign address, enter a period (.).
See IRM 3.24.38.
(18)
ZIP Code
ZIP
Enter the ZIP Code.
If a foreign address, press
(19)
Preparation Code
PREP
Enter the edited code from the right of the Preparer PTIN line.
(20)
Preparer PTIN
PTIN
Enter the Preparer's PTIN.
(21)
Preparer EIN
PEIN
Enter the Preparer's EIN from the Preparer EIN box.
(22)
Preparer Telephone
PTEL
Enter the Preparer's phone number from the Preparer's phone number box.
Form 5227 - Section 02, Form 5800 - Edit Sheet¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
ERS Action Code
BOTLFMAR
Enter the edited digits from the bottom left margin of the return.
If the ERS Action Code is in the "600" series and the return is a non-remittance, end the document after this element.
If the ERS Action Code is in the "600" series and the return is a remittance, press
If a "G" Condition Code is present and the return is a remittance, press
(3)
Audit Code
LN2
Enter the edited digit from Line 2, Form 5800.
(4)
CAF Code
LN3
Enter the edited digit from Line 3, Form 5800.
(5)
Correspondence Code
LN4
Enter the edited digits from Line 4, Form 5800.
(6)
Correspondence Received Date
LN5
Enter the edited digits from Line 5, Form 5800, in MMDDYY format.
For special instructions, see IRM 3.24.38.
(7)
Penalty and Interest Code
LN6
Enter the edited digit from Line 6, Form 5800.
(8)
Daily Delinquency Penalty
LN7
Enter the amount from Line 7, Form 5800.
Form 5227 - Section 03¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Remittance Amount
RMT
Enter the edited amount shown in the margin at the top of the return.
Check the control document (Form 813) for correct amount in case of illegibility.
Enter the RPS amount printed on the upper right corner of the return ONLY if underlined in green.
If a "G" Condition Code is present, end the document after this element.
This is a MUST ENTER if Pre-journalized Credit Amount E–(5), Block Header, was entered.
The error message INVALID DATA appears if there is an amount in this field and no entry for Pre-journalized Credit Amount in the Block Header.
(3)
Fair Market Value
BOXC $
Enter the amount from Box D.
(4)
Gross Income
BOXD $
Enter the amount from Box E.
(5)
Total Ordinary Income
LN8 $
Enter the amount from Part I, Line 8.
(6)
Total Capital Gain (loss)
L13 $
Enter the amount from Part I, Line 13.
(7)
Total Deductions
L22 $B
Enter the amount from Part I, Line 22.
(8)
Total Distributions of Principal
PTIII4
Enter the amount from Form 5227, Part III, Section A, Line 4.
(9)
Total Distributions of Income
PTIII9
Enter the amount from Form 5227, Part III, Section B, Line 9.
(10)
Total Assets (EOY)
PTIV13B
Enter the amount from Part IV, Line 13, Column (b).
(11)
Total Assets (FMV)
PTIV13C
Enter the amount from Part IV, Line 13, Column (c).
(12)
Total Liabilities (EOY)
PTIV 19B
Enter the amount from Part IV, Line 19, Column (b).
(13)
Total Annual Annuity
PTIV23B
Enter the amount from Part V, Line 1b.
(14)
NICRUT
PTVL2
Enter a yes or no from the yes/no box from Part VI, Line 1.
(15)
NIMCRUT
PTVL3
Enter a yes or no from the yes/no box from Part VI, Line 2
(16)
Unitrust Amount
PTVL5B
Enter the amount from Part VI, Line 4b.
Form 5227 - Section 04¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Engage in the Sale?
PTVIIA1
Enter a yes or no from the yes/no box from Part VIII, Line 1a(1).
(3)
Borrow Money from?
PTVIIA2
Enter a yes or no from the yes/no box from Part VIII, Line 1a(2).
(4)
Furnish Goods?
PTVIIA3
Enter a yes or no from the yes/no box from Part VIII, Line 1a(3).
(5)
Pay Compensation?
PTVIIA4
Enter a yes or no from the yes/no box from Part VIII, Line 1a(4).
(6)
Transfer any of your Income?
PTVIIA5
Enter a yes or no from the yes/no box from Part VIII, Line 1a(5).
(7)
Agree to Pay Money?
PTVIIA6
Enter a yes or no from the yes/no box from Part VIII, Line 1a(6).
(8)
Fail to Qualify Under Exceptions?
PTVIIIB
Enter a yes or no from the yes/no box from Part VIII, Line 1b.
(9)
Engage in Prior Year?
PTVIIIC
Enter a yes or no from the yes/no box from Part VIII, Line 1d.
(10)
Income Interest Expired?
PTIX1
Enter a "1" if the box in Part IX, Line 1 is checked.
(11)
Making an Election Under Regulation
PTIXI2
Enter a yes or no from the yes/no box from Part IX, Section D, Line 12.
(12)
Initial Return
PTIXI3
Enter a yes or no from the yes/no box from Part IX, Section D, Line13.
(13)
Trust Instrument Amended?
PTIXI4
Enter a yes or no from the yes/no box from Part IX, Section D, Line 14.
(14)
Final Distributions Made?
D15a
Enter a yes or no from the yes/no box from Part IX, Section D, Line 15a.
Form 5227 - Section 05¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Accum. Dist. from Ordinary Excluded Income
2B(A)1 $
Enter the amount from Schedule A, Part I, Line 2b, Column (a) ordinary excluded income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(3)
Distributions from Ordinary Accumulated NII Income
2B(A)2 $
Enter the amount from Schedule A, Part I, Line 2b, Column (a), ordinary accumulated NII income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(4)
Dist. from Capital Gain Excluded Income
2B(B)1 $
Enter the amount from Schedule A, Part I, Line 2b, Column (b) capital gain excluded income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(5)
Distributions form Capital Gain Accumulated NII Income
2B(B)2 $
Enter the amount from Schedule A, Part I, Line 2b, Column (b), capital gain accumulated NII income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(6)
Distributions from Nontaxable Excluded Income
2B(C)1 $
Enter the amount from Schedule A, Part I, Line 2b, Column (c), nontaxable excluded income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(7)
Distributions from Nontaxable Accumulated NII Income
2B(C)2 $
Enter the amount from Schedule A, Part I, Line 2b, Column (c), nontaxable accumulated NII income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(8)
Undist. Excluded Ordinary Income
3(A)1 $
Enter the amount from Schedule A, Part I, Line 3, Column (a) ordinary excluded income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(9)
Undistributed Accumulated NII Ordinary Income
3A2 $
Enter the amount from Schedule A, Part I, Line 3, Column (a), accumulated NII income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(10)
Undist. Capital Gains Excluded Income
3(B)1 $
Enter the amount from Schedule A, Part I, Line 3, Column (b), capital gains excluded income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(11)
Undistributed Capital Gains Accumulated NII Income
3B2 $
Enter the amount from Schedule A, Part I, Line 3, Column (b), capital gains accumulated NII income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(12)
Undistributed Nontaxable Excluded Income
3C1 $
Enter the amount from Schedule A, Part I, Line 3, Column (c), nontaxable excluded income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(13)
Undistributed Nontaxable Accumulated NII Income
3C2 $
Enter the amount from Schedule A, Part I, Line 3, Column (c), nontaxable accumulated NII income.
Enter only the money amount in the first excluded column for 2012 and prior year returns.
(14)
Simplified Net Investment Income Current Year
L4B $
Enter the amount from Schedule A, Part II, Line 1, Column (b), current year NII.
(15)
Simplified Net Investment Income Distributions
L4C $
Enter the amount from Schedule A, Part II, Line 1, Column (c), distributions.
(16)
Simplified Net Investment Ending NII
L4D $
Enter the amount from Schedule A, Part II, Line 1, Column (d), ending NII.
(17)
Additional Assets Contributed
LV1
Enter a yes or no from the yes/no box from Schedule A, Part V, Line 1.
(18)
Total Fair Market Value of Assets
LV4C
Enter the amount from Schedule A, Part V, Line 4, total.
(19)
Early Termination Agreement Signed?
LV5
Enter a yes or no from the yes/no box from Schedule A, Part V, Line 5.
Form 5227 - Section 13, Form 8995/8995A¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Press
(2)
Part IV Qualified Business Income
L5/L27
Enter the amount from Line 5 or Line 27 as follows:
Enter the amount from Form 8995 Line 5, if present and press Enter.
Enter the amount from Form 8995-A, Part IV, Line 27, if present and press Enter.
(3)
Part IV REIT/PTP Component
L9/L31
Enter the amount from Line 9 or Line 31 as follows:
Enter the amount from Form 8995, Line 9, if present and press Enter.
Enter the amount from Form 8995-A, Part IV, Line 31 if present and press Enter.
(4)
Part IV Net Capital Gains
L12/L34
Enter the amount from line 12 or line 34 as follows:
Enter the amount from Form 8995 line 12, if present, and press Enter.
Enter the amount from Form 8995-A Part IV line 34, if present, and press Enter.
(5)
Part IV Domestic Production Activities Section 199A(g)
L38
Enter the amount from Form 8995-A Part IV line 38.
Form 5578 - Section 01¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Section "01" always generates. No entry required.
(2)
Serial Number
SER#
Enter the last two digits of the 13-digit DLN from the upper portion of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4
(4)
Name Control
NC
If the Check Digit isn't present, enter the Name Control.
See IRM 3.24.12.3.4
(5)
Employer Identification Number
EIN
Enter the EIN from the preprinted label or from EIN block.
See standard rules in IRM 3.24.38.
For error message CHECK DIGIT ERROR, see IRM 3.24.12.3.4
(6)
Tax Period
TAXPR
Enter in YYMM format the Tax Period edited or underlined under "title of form" .
If not edited or underlined, press
See IRM 3.24.38 for special instructions.
(7)
Condition Code
CC
Enter the edited code as shown in the upper right corner of the return.
If illegible, enter a "#" .
Form 5768 - Section 01 (Program 15502)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Section "01" always generates. No entry required.
(2)
Serial Number
SER#
Enter the last 2 digits of the 13 digit DLN from the DLN box, upper right margin or top center margin of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Name Control
NC
Enter the Name Control as follows:
Enter the 4 character Name Control underlined or edited in the first name line area.
If less than 4 characters, enter those shown followed by
If Name Control is illegible, enter 1 period and
(4)
Employer Identification Number
EIN
Auto
Enter the 9 digit number from the area labeled "EIN" , or "Employer Identification Number" on the form.
If two account numbers are shown, enter 9 periods.
See standard rules in IRM 3.24.38.
Note:¶
E–(5) thru (8) must be present for Document 00.
Note:¶
If E–(5) thru (11) are the same as the previous document, press
(5)
MFT Code
MFT
Enter the MFT Code as follows:
Form 5768 - enter "00" .
If illegible or missing, enter a zero (0) and
(6)
Report/Plan Number
RPT#
Enter the edited 3 digit code shown to the right of the MFT Code.
If MFT is 46 or 76, then "RPT#" is a "MUST ENTER" field.
If not present, enter one zero (0) and press
(7)
Tax Period
TAXPR
Enter the four digits in YYMM format.
Form 5768 - enter "0000"
For special instructions, see IRM 3.24.38.
(8)
Transaction Code
CODE
Enter the three digit Transaction Code from Line 1 or 2 left margin.
If illegible or missing, enter "000" .
(9)
Transaction Date
DATE
Enter the digits from "Date Received" or "Date" in MMDDYY format.
If date isn't present, illegible or incomplete, enter the earlier of today's date or 4/15/19.
For special instructions, see IRM 3.24.38.
(10)
Extension to Date
EXT DATE
press
For special instructions, see IRM 3.24.38.
(11)
EO Group Code
EOGRP
Enter the digit "7" or "8" shown in the right middle margin of the two dots.
Form 5768 - press
(12)
Lobby Year Code
LOB YR
Enter the 2 digits underlined on dotted portion of Line 1 or 2 in YY format.
For special instructions, see IRM 3.24.38.
(13)
Account Number (TIN) Prefix
ANP
Enter the edited zero (0) if present, following the TIN.
(14)
ERS Action Code
ERSCD
Enter the ERS Action Code edited on the bottom left margin of the return.
Form 8872 - Section 01 (Program 16010)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Section "01" always generates. No entry required.
(2)
DLN Serial Number
SER#
Enter the last 2 digits of the 13-digit DLN from the DLN box, upper right margin or top center margin of the form.
If the system generates the serial number verify it matches the document being entered.
See IRM 3.24.38.4.1.1
(3)
Check Digit
CD
Enter the Check Digit if present.
If not present, press
See IRM 3.24.12.3.4
(4)
Name Control
NC
If a Check Digit isn't present, enter the Name Control as follows:
Enter the 4 character Name Control underlined or edited in the first name line area.
If less than 4 characters, enter those shown followed by
If Name Control is illegible, enter 1 period and
Note:¶
"ZZZZ" is valid.
(5)
Employer Identification Number
EIN
Enter the 9-digit number from the area labeled "EIN" , or "Employer Identification Number" on the form.
If two account numbers are shown, enter 9 periods.
See standard rules in IRM 3.24.38.
For error message CHECK DIGIT ERROR, see IRM 3.24.12.2.5
(6)
Address Check
ADDRESS CHECK
Enter "Y" or "N" as appropriate.
(7)
Street Key
STREET KEY#
See IRM 3.24.28.
(8)
ZIP KEY
ZIP KEY
See IRM 3.24.38.
(9)
Tax Period
TAXPR
Enter in YYMM format the edited digits to the left of the OMB Number.
For special instructions, see IRM 3.24.38.
(10)
Condition Codes
CCC
Enter the edited codes shown on Line B.
If a "G" Condition Code is present and the return is a non-remittance, end the document after the Received Date.
(11)
Received Date
RDATE
Enter in MMDDYY format.
For special instructions, see IRM 3.24.38.
(12)
Correspondence Indicator
COR
Enter the edited digits to the right of the City/State line.
(13)
Correspondence Received Date
CRD
Enter the edited digits to the right of the Correspondence Indicator.
(14)
ERS Action Code
ERS
Enter the edited digits in the lower left margin of the form.
(15)
Audit Code
AUD
Enter from the bottom right margin of the form.
Form 8872 - Section 02 (Program 16010)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
Note:¶
1: For good labels with no changes and a solid or broken black line above and to the left of the entity area, see IRM 3.24.38.
(2)
Street Address
ADD#
Enter the street address from the address line - Line 2.
If a "G" Condition Code or a foreign address is present on the return, do NOT enter any of the address information, even if prompted. This occurs when a Name Control is entered.
See IRM 3.24.28 for specific instructions.
(3)
Second/Foreign Address
ADD2
Enter the second/foreign street address, if shown.
See IRM 3.24.38 for additional instructions.
(4)
City
CITY
Enter the city name from the city line, or Major City Code, if appropriate.
(5)
State
ST
Enter the standard state abbreviation from the city/state line.
If a Major City Code was entered, press
See IRM 3.24.38.
(6)
ZIP Code
ZIP
Enter the ZIP Code.
Form 8872 - Section 03 (Program 16010)¶
Elem.
Data Element Name
Prompt
Fld. Term.
Instructions
(1)
Section Number
SECT:
(2)
Type of Report
LN8#
Enter the digit edited to the right of Line 8.
If missing, enter a "1" through "8" representing the box checked for "a" through "h" on Line 8.
(3)
Amount of Reported Contributions
LN9 $
Enter amount shown on Line 9.
(4)
Amount of Reported Expenditures
L10 $
Enter amount shown on Line 10.
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