Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| PART 1, LINE 8 | OTHER REVENUE |
| PART 1 LINE 8 | SURPLUS LINES: $1,700.07 |
| PART 1, LINE 8 | 2% PREMIUM TAX: $21,983.10 |
| PART 1, LINE 16 | NJSFA SURPLUS LINES ASSESSEMENT: $1,020.04 |
| PART 1, LINE 16 | NJSFA 2% PREMIUM TAX ASSESSMENT: $13,189.86 |
| PART 1, LINE 16 | NJ SECRETARY OF STATE FILING FEE: $30.50 |
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