TY 2019 Form 990EZ

- TIN:

Form990EZ

Department of the Treasury
Internal Revenue Service

Short Form
Return of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)

Do not enter social security numbers on this form as it may be made public.

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-1150

2019

Open to Public
Inspection

For the 2019 calendar year, or tax year beginning 01-01-2019, and ending 12-31-2019

Check if applicable:

Address change

Name change

Initial return

Final return/terminated

Amended return

Application pending

C Name of organization
NEW CANAAN POLICE BENEVOLENT
ASSOCIATION INC

Number and street (or P. O. box, if mail is not delivered to street address)PO BOX 508
Room/suite

City or town, state or province, country, and ZIP or foreign postal code NEW CANAAN, CT06840

D Employer identification number

23-7225069

E Telephone number

(203) 594-3500

F Group Exemption
Number bullet

G Accounting Method: CashAccrualOther (specify) bullet

H Check bullet

required to attach Schedule B
(Form 990, 990-EZ, or 990-PF).I Website: bullet

N/AJ Tax-exempt status (check only one) - 501(c)(3) 501(c)( 5) bullet

(insert no.) 4947(a)(1) or 527

K Form of organization: CorporationTrustAssociationOther

L Add lines 5b, 6c, and 7b to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part II, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ ........................... bullet

$ 132,824

Part Ⅰ

Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I) Check if the organization used Schedule O to respond to any question in this Part I.....................

1	Contributions, gifts, grants, and similar amounts received ....................	1	16,810
2	Program service revenue including government fees and contracts ................	2
3	Membership dues and assessments .............................	3
4	Investment income ....................................	4	4,194
5a	Gross amount from sale of assets other than inventory .......	5a
b	Less: cost or other basis and sales expenses ............	5b
c	Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ......	5c
6	Gaming and fundraising events
a	Gross income from gaming (attach Schedule G if greater than $15,000)	6a
b	Gross income from fundraising events (not including $ of contributions from fundraising events reported on line 1) (attach Schedule G if the			sum of such gross income and contributions exceeds $15,000) ..	6b	111,820
c	Less: direct expenses from gaming and fundraising events ...	6c	75,566
d	Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c)	6d	36,254
7a	Gross sales of inventory, less returns and allowances ......	7a
b	Less: cost of goods sold .............	7b
c	Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) .........	7c
8	Other revenue (describe in Schedule O) ....................	8
9	Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 ..............	9	57,258

10	Grants and similar amounts paid (list in Schedule O) ................	10	28,050
11	Benefits paid to or for members ......................	11
12	Salaries, other compensation, and employee benefits ................	12
13	Professional fees and other payments to independent contractors ............	13	985
14	Occupancy, rent, utilities, and maintenance ...................	14	5,264
15	Printing, publications, postage, and shipping ...................	15	206
16	Other expenses (describe in Schedule O) ...................	16	19,902
17	Total expenses. Add lines 10 through 16 .................	17	54,407

18	Excess or (deficit) for the year (Subtract line 17 from line 9) ............	18	2,851
19	Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
	end-of-year figure reported on prior year’s return) .................	19	156,212
20	Other changes in net assets or fund balances (explain in Schedule O) ...........	20	0
21	Net assets or fund balances at end of year. Combine lines 18 through 20 ..........	21	159,063

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 10642I Form 990-EZ (2019)

Form 990-EZ (2019)

Page 2

Part ⅡBalance Sheets (see the instructions for Part II)Check if the organization used Schedule O to respond to any question in this Part II.................

(A) Beginning of year(B) End of year

22Cash, savings, and investments................

156,212

159,063

23Land and buildings....................

24Other assets (describe in Schedule O) ..........

25Total assets......................

156,212

159,063

Total liabilities (describe in Schedule O) .............

27Net assets or fund balances (line 27 of column (B) must agree with line 21)

156,212

159,063

Part ⅢStatement of Program Service Accomplishments (see the instructions for Part III) Check if the organization used Schedule O to respond to any question in this Part III . .	Expenses (Required for section 501(c)(3) and 501(c)(4) organizations; optional for others.)
What is the organization's primary exempt purpose? TO ENHANCE THE EFFICIENCY OF POLICE; TO UPHOLD THE CONSTITUION AND THE LAWS OF THE UNITED STATES AND THE STATE OF CONNECTICUT, AND THE ORDINANCES AND REGULATIONS OF THE TOWN OF NEW CANAAN, TO PREVENT CRIME AND TO DETECT VIOLATIONS OF LAW, TO PROMOTE RESPECT FOR LAW AND ORDER, TO ASSIST IN THE ADMINISTRATION OF JUSTICE, TO PROMOTE AND CONDUCT EDUCATIONAL ACTIVITIES AMONG ITS MEMBERS TO ENDS THAT METHODS AMD MEANS MAY BE FORMULATED BEST SUITED FOR THE NEEDS OF THE COMMUNITY OF THE TOWN OF NEW CANAAN FOR THE PREVENTION OF CRIME AND DETENTION THEREOF; TO RENDER MUTUAL AID ASSISTANCE TO ITS MEMBERS AND THEIR DEPENDENTS AND TO PROMOTE SUCH SOCIAL AND INTELLECTUAL INTERCOURSE AMONG ITS MEMBERS AS SHALL BE DESIRABLE AND PROPER AND IN SUCH MANNER AS THEY DEEM BEST, TO MAINTAIN AMICABLE RELATIONS BETWEEN ITS MEMBERS ANDS THEIR SUPERIORS, AND IN GENRAL, TO FOSTER AND ADVANCE THE MORALE AND EFFICIENCY OF ITS MEMBERS IN THEIR LINE OF DUTY.
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 RETIRED OFFICERS YEAR END HOLIDAY BENEFIT DISTRIBUTIONS (Grants $ 0) If this amount includes foreign grants, check here ...			28a	26,450
29 GOLF TOURNAMENT (Grants $ 0) If this amount includes foreign grants, check here ...			29a	12,550
30 ANNUAL CHILDREN'S CHRISTMAS PARTY AND ANNUAL PBA CHRISTMAS PARTY IN NEW CANAAN CONNECTICUT (Grants $ 0) If this amount includes foreign grants, check here ...			30a	993
OTHER YOUTH SPORT PROGRAMS IN NEW CANAAN CONNECTICUT (Grants $ 0) If this amount includes foreign grants, check here ...		0
31 Other program services (describe in Schedule O) ................ (Grants $ ) If this amount includes foreign grants, check here...	31a
32 Total program service expenses (add lines 28a through 31a)..........	32	39,993

Part Ⅳ

List of Officers, Directors, Trustees, and Key Employees (list each one even if not compensated see the instructions for Part IV)Check if the organization used Schedule O to respond to any question in this Part IV............

(a) Name and title	(b) Average hours per week devoted to position	(c) Reportable compensation (Forms W-2/1099-MISC) (if not paid, enter -0-)	(d) Health benefits, contributions to employee benefit plans, and deferred compensation	(e) Estimated amount of other compensation
ROBERTO LOPEZ PRESIDENT-EXECUTIVE COMMIT	1.00	0	0	0
ROB BENTLEY VICE. PRES.-EXECUTIVE COMM	0.25	0	0	0
DANIEL GULINO SECRETARY-EXECUTIVE COMMIT	0.25	0	0	0
GEORGE CAPONERA TREASURER-EXECUTIVE COMMIT	0.25	0	0	0

Form 990-EZ (2019)

Page 3

Part Ⅴ

Other Information

(Note the Schedule A and personal benefit contract statement requirements in the

instructions for Part V.) Check if the organization used Schedule O to respond to any question in this Part V.......

Yes

Did the organization engage in any significant activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ...................

Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the changeon Schedule O. See instructions. ..........................

35a

Did the organization have unrelated business gross income of $1,000 or more during the year from business activities (such as those reported on lines 2, 6a, and 7a, among others)? ............

35a

If "Yes," to line 35a, has the organization filed a Form 990-T for the year? If "No," provide an explanation in Schedule O

35b

Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements during the year? If "Yes," complete Schedule C, Part III

35c

Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes," complete applicable parts of Schedule N ................

37a

Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet

37a

Did the organization file Form 1120-POL for this year?...................

37b

38a

Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were

any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?..

38a

If “Yes," complete Schedule L, Part II and enter the total amount involved .

38b

Section 501(c)(7) organizations. Enter:

Initiation fees and capital contributions included on line 9.......

39a

Gross receipts, included on line 9, for public use of club facilities.....

39b

40a

Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:

section 4911 bullet

; section 4912 bullet

; section 4955 bullet

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year, or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes," complete Schedule L, Part I

40b

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 bullet

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Enter amount of tax on line 40c reimbursed by the organization bullet

All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T ................

40e

41List the states with which a copy of this return is filed. bullet

42aThe organization's books are in care of bullet

GEORGE CAPONERA
Telephone no. bullet

(203) 594-3500

Located at bullet

174 SOUTH AVENUENEW CANAAN,CT ZIP + 4 bullet

06840

Yes

At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)? . .

42b

If “Yes," enter the name of the foreign country: bullet

See the instructions for exceptions and filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).

At any time during the calendar year, did the organization maintain an office outside the U.S.? . . .

42c

If “Yes," enter the name of the foreign country: bullet

43 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041 - Check here ...... bullet

and enter the amount of tax-exempt interest received or accrued during the tax year.... bullet

Yes

44a

Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must be completed insteadof Form 990-EZ.............................

44a

Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be completedinstead of Form 990-EZ.............................

44b

Did the organization receive any payments for indoor tanning services during the year?.........

44c

If "Yes," to line 44c, has the organization filed a Form 720 to report these payments? If "No," provide an
explanation in Schedule O ............................

44d

45a

Did the organization have a controlled entity within the meaning of section 512(b)(13)?.........

45a

45b

Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," Form 990 and Schedule R may need to be completed instead of Form 990-EZ (see instructions)......................

45b

Form 990-EZ (2019)

Page 4

Yes

Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition tocandidates for public office? If “Yes," complete Schedule C, Part I. ...........

Part Ⅵ

Section 501(c)(3) Organizations Only All section 501(c)(3) organizations must answer questions 47- 49b and 52, and complete the tables for lines 50 and 51. Check if the organization used Schedule O to respond to any question in this Part VI ..................

Yes

Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II .......................

Is the organization a school as described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E ..

49a

Did the organization make any transfers to an exempt non-charitable related organization?......

49a

If "Yes," was the related organization a section 527 organization?................

49b

Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."

(a) Name and title of each employee	(b) Average hours per week devoted to position	(c) Reportable compensation (Forms W-2/1099-MISC)	(d) Health benefits, contributions to employee benefit plans, and deferred compensation	(e) Estimated amount of other compensation

Total number of other employees paid over $100,000 ............. bullet

Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."

(a) Name and business address of each independent contractor	(b) Type of service	(c) Compensation

Total number of other independent contractors each receiving over $100,000.......... bullet

Did the organization complete Schedule A? NOTE. All section 501(c)(3) organizations must attach a
completed Schedule A ........................................ bullet

Yes No

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Sign Here

	Signature of officer	Date

	Type or print name and title

Paid Preparer Use Only

Print/Type preparer's name

Preparer's signature

Date

Check if
self-employed

PTIN

Firm's name bullet

Firm's EIN bullet

Firm's address bullet

Phone no.

May the IRS discuss this return with the preparer shown above? See instructions ......... bullet

YesNo

Form 990-EZ (2019)

Additional Data

Software ID:
Software Version:

Form 990-EZ, Special Condition Description:

Special Condition Description

- TIN:

SCHEDULE G (Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" on Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. right arrow

Attach to Form 990 or Form 990-EZ.
right arrow

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization
NEW CANAAN POLICE BENEVOLENT
ASSOCIATION INC

Employer identification number

23-7225069

Part I

Fundraising Activities.Complete if the organization answered "Yes" on Form 990, Part IV, line 17.

Form 990-EZ filers are not required to complete this part.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and email solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

YesNo

If "Yes," list the 10 highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.

(i) Name and address of individual or entity (fundraiser)	(iii) Did fundraiser have custody or control of contributions?
	Yes	No










Total . . . . . . . . . . . . . . . . . . . .

List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from registration or licensing.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2019

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" on Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.

		(a) Event #1 TCIA FUNDRAISING CAMPAIGN (event type)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . . . .	111,820	111,820
2	Less: Contributions . . . .
3	Gross income (line 1 minus line 2) . . . . . .	111,820	111,820

4	Cash prizes . . . . .
5	Noncash prizes . . . .
6	Rent/facility costs . . . .
7	Food and beverages . . .
8	Entertainment . . . .
9	Other direct expenses . . .	63,016	12,550	75,566
10	Direct expense summary. Add lines 4 through 9 in column (d) . . . . . . . . . .			75,566
11	Net income summary. Subtract line 10 from line 3, column (d). . . . . . . . . .			36,254

Part III

Gaming. Complete if the organization answered "Yes" on Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

		(a) Bingo	(b) Pull tabs/Instant bingo/progressive bingo	(c) Other gaming	(d) Total gaming (add col.(a) through col.(c))
1	Gross revenue . . . . .

2	Cash prizes . . . . .
3	Noncash prizes . . . .
4	Rent/facility costs . . . .
5	Other direct expenses . . .

Volunteer labor . . . .

	Yes %
	No

	Yes %
	No

	Yes %
	No

Direct expense summary. Add lines 2 through 5 in column (d) . . . . . . . . . . right arrow

Net gaming income summary. Subtract line 7 from line 1, column (d). . . . . . . . . right arrow

Enter the state(s) in which the organization conducts gaming activities:

Is the organization licensed to conduct gaming activities in each of these states? . . . . . . . .

YesNo

If "No," explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? . . .

YesNo

If "Yes," explain:

Schedule G (Form 990 or 990-EZ) 2019

Page 3

Does the organization conduct gaming activities with nonmembers? . . . . . . . . . . .

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? . . . . . . . . . . . . . . . . .

YesNo

Indicate the percentage of gaming activity conducted in:

The organization's facility . . . . . . . . . . . . . . . . . .

13a

An outside facility . . . . . . . . . . . . . . . . . . . .

13b

Enter the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? . . . . . . . . . . . . . . . . . . . . . . . .

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address of the third party:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? . . . . . . . . . . . . . . . . . . .

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Supplemental Information. Provide the explanations required by Part I, line 2b, columns (iii) and (v); and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also provide any additional information. See instructions.

Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

NEW CANAAN POLICE BENEVOLENT
ASSOCIATION INC

Employer identification number

23-7225069

Return Reference	Explanation
FORM 990-EZ, PART I, LINE 4 - OTHER INVESTMENT INCOME	DESCRIPTION: DIVIDENDS. AMOUNT: 3,307. DESCRIPTION: CAPITAL GAINS DISTRIBUTIONS. AMOUNT: 887. TOTAL INCLUDED ON FORM 990-EZ, LINE 4: 4,194.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: YEAR END RETIRED OFFICERS BENEFIT DISTRIBUTIONS $1,100 TO 26 INDIVIDUALS. GRANTEE NAME: NONE IN EXCESS OF $5,000. AMOUNT GIVEN: 26,450.
FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID	ACTIVITY CLASSIFICATION: DONATIONS TO NEW CANAAN CHARITIES. GRANTEE NAME: NONE IN EXCESS OF $5,000. AMOUNT GIVEN: 1,600. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 28,050.
FORM 990-EZ, PART I, LINE 14	DESCRIPTION: DEPRECIATION. AMOUNT: 3,445. DESCRIPTION: OTHER EXPENSES. AMOUNT: 1,819. TOTAL TO FORM 990-EZ, LINE 14: 5,264.
FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES	DESCRIPTION: FLOWERS FOR FUNERALS. AMOUNT: 1,103. DESCRIPTION: BANK CHARGES. AMOUNT: 114. DESCRIPTION: INVESTMENT FEES. AMOUNT: 1,370. DESCRIPTION: DAY ROOM. AMOUNT: 1,237. DESCRIPTION: TRIPLE AAA. AMOUNT: 352. DESCRIPTION: CHILDREN'S CHRISTMAS PARTY. AMOUNT: 810. DESCRIPTION: CHRISTMAS PARTY. AMOUNT: 188. DESCRIPTION: OTHER. AMOUNT: 100. DESCRIPTION: PAC MEETINGS/FEES/DUES. AMOUNT: 1,198. DESCRIPTION: FLAGS FOR GRAVES. AMOUNT: 296. DESCRIPTION: SOFTBALL TOURNAMENT. AMOUNT: 2,786. DESCRIPTION: 4TH PARTY. AMOUNT: 648. DESCRIPTION: RETIREMENT GIFT. AMOUNT: 1,069. DESCRIPTION: TREASURER STIPEND. AMOUNT: 300. DESCRIPTION: FISHING DERBY. AMOUNT: 3,587. DESCRIPTION: HALLOWEEN CANDY. AMOUNT: 85. DESCRIPTION: PBA DINNER. AMOUNT: 1,989. DESCRIPTION: SPECIAL OLYMPICS . AMOUNT: 349. DESCRIPTION: GREGGS GARDEN CENTER. AMOUNT: 1,252. DESCRIPTION: KIDZFEST. AMOUNT: 400. DESCRIPTION: POST PROM. AMOUNT: 414. DESCRIPTION: PERKINS SHOOT . AMOUNT: 255. TOTAL TO FORM 990-EZ, LINE 16: 19,902.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

TY 2019 TransferPrsnlBnftContractsDecl

Name:

NEW CANAAN POLICE BENEVOLENT

ASSOCIATION INC

EIN:

23-7225069

Declaration:

THE ORGANIZATION DID NOT, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY,OR INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT.THE ORGANIZATION, DID NOT, DURING THE YEAR, PAY ANY PREMIUMS, DIRECTLY,OR INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT.