STRATEGY STUDIO / PUBLIC DATA EXPLORER

AMERICAN FRIENDS OF KUPAT HAIR INC: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization
AMERICAN FRIENDS OF KUPAT HAIR INC (EIN 20-1523797)
Tax period
2012-01-01 to 2012-12-31
Filed
2013-11-15
IRS object ID
201333199349303193
Schema version
2012v2.3
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2013-11-15T09:43:19-06:00Timestamp
Tax Period End Date2012-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1ROTH & COMPANY LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line11428 36TH STREET SUITE 200AddressLine1
CityBROOKLYNCity
StateNYState
ZIP Code11218ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2012-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN201523797EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1AMERICAN FRIENDS OF KUPAT HAIRBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlAMERNameControl
Phone7189728970Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line14415 14TH AVENUEAddressLine1
CityBROOKLYNCity
StateNYState
ZIP Code11219ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameYOSEF FISHMANName
TitlePRESIDENTTitle
Phone7189728970Phone
Date Signed2013-11-04DateSigned
Authorize Third PartytrueAuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameSOLOMON EISNERName
Phone7182361600Phone
Date Prepared2013-11-15DatePrepared
FieldValueIRS element (for citing)
Tax Year2012TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonYOSEF FISHMANNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line11234 44TH STREETAddressLine1
CityBROOKLYNCity
StateNYState
ZIP Code11219ZIPCode
FieldValueIRS element (for citing)
Gross Receipts4066298GrossReceipts
Group Return For AffiliatesfalseGroupReturnForAffiliates
Organization501c3XOrganization501c3
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation2003YearFormation
State Legal DomicileNYStateLegalDomicile
Activity Or Mission DescriptionTO RAISE FUNDS FOR DISTRIBUTION TO INSTITUTIONS ORGANIZED AND OPERATED EXCLUSIVELY FOR RELIGIOUS, CHARITABLE AND EDUCATIONAL PURPOSES IN THE UNITED STATES AND ISRAEL WITH A VIEW TOWARD PROVIDING AID, ASSISTANCE AND SUPPORT TO NEEDY AND INDIGENT INDIVIDUALS IN ISRAEL AND THE UNITED STATES.ActivityOrMissionDescription
Nbr Voting Members Governing Body5NbrVotingMembersGoverningBody
Nbr Independent Voting Members5NbrIndependentVotingMembers
Total Nbr Employees6TotalNbrEmployees
Total Nbr Volunteers5TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Contributions Grants Prior Year4342682ContributionsGrantsPriorYear
Contributions Grants Current Year4064746ContributionsGrantsCurrentYear
Program Service Revenue CY0ProgramServiceRevenueCY
Investment Income Prior Year866InvestmentIncomePriorYear
Investment Income Current Year1552InvestmentIncomeCurrentYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Prior Year4343548TotalRevenuePriorYear
Total Revenue Current Year4066298TotalRevenueCurrentYear
Grants And Similar Amnts CY3123120GrantsAndSimilarAmntsCY
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year58482SalariesEtcPriorYear
Salaries Etc Current Year53198SalariesEtcCurrentYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year815041TotalFundrsngExpCurrentYear
Other Expense Prior Year4199606OtherExpensePriorYear
Other Expenses Current Year882764OtherExpensesCurrentYear
Total Expenses Prior Year4258088TotalExpensesPriorYear
Total Expenses Current Year4059082TotalExpensesCurrentYear
Revenues Less Expenses Prior Year85460RevenuesLessExpensesPriorYear
Revenues Less Expenses CY7216RevenuesLessExpensesCY
Total Assets BOY319684TotalAssetsBOY
Total Assets EOY338067TotalAssetsEOY
Total Liabilities BOY27895TotalLiabilitiesBOY
Total Liabilities EOY39062TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY291789NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY299005NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTO RAISE FUNDS FOR DISTRIBUTION TO INSTITUTIONS ORGANIZED AND OPERATED EXCLUSIVELY FOR RELIGIOUS, CHARITABLE AND EDUCATIONAL PURPOSES IN THE UNITED STATES AND ISRAEL WITH A VIEW TOWARD PROVIDING AID, ASSISTANCE AND SUPPORT TO NEEDY AND INDIGENT INDIVIDUALS IN ISRAEL AND THE UNITED STATES.MissionDescription
Significant New Program ServicesfalseSignificantNewProgramServices
Significant ChangefalseSignificantChange
Expense3126449Expense
Grants3123120Grants
Revenue4064776Revenue
DescriptionTO RAISE FUNDS FOR DISTRIBUTION TO INSTITUTIONS ORGANIZED AND OPERATED EXCLUSIVELY FOR RELIGIOUS, CHARITABLE AND EDUCATIONAL PURPOSES IN THE UNITED STATES AND ISRAEL WITH A VIEW TOWARD PROVIDING AID, ASSISTANCE AND SUPPORT TO NEEDY AND INDIGENT INDIVIDUALS IN ISRAEL AND THE UNITED STATES.Description
Total Program Service Expense3126449TotalProgramServiceExpense
Described In501 C3trueDescribedIn501C3
Schedule B RequiredfalseScheduleBRequired
Political ActivitiesfalsePoliticalActivities
Lobbying ActivitiesfalseLobbyingActivities
Subject To Proxy TaxfalseSubjectToProxyTax
Donor Advised FundsfalseDonorAdvisedFunds
Conservation EasementsfalseConservationEasements
Collections Of ArtfalseCollectionsOfArt
Credit CounselingfalseCreditCounseling
Term Or Permanent EndowmentsfalseTermOrPermanentEndowments
Report Land Bldg EquipfalseReportLandBldgEquip
Report Invest Oth SecuritiesfalseReportInvestOthSecurities
Report Prog Rel InvestfalseReportProgRelInvest
Report Other AssetsfalseReportOtherAssets
Report Other LiabilitiesfalseReportOtherLiabilities
Report Fin48 FootnotefalseReportFin48Footnote
Independent Audit Financial StmtfalseIndependentAuditFinancialStmt
Consolidated Audit Financial StmtfalseConsolidatedAuditFinancialStmt
SchoolfalseSchool
Foreign OfficefalseForeignOffice
Foreign ActivitiesfalseForeignActivities
More Than5000 K To OrganizationstrueMoreThan5000KToOrganizations
More Than5000 K To IndividualsfalseMoreThan5000KToIndividuals
Professional FundraisingfalseProfessionalFundraising
Fundraising ActivitiesfalseFundraisingActivities
GamingfalseGaming
HospitalfalseHospital
Grants To OrganizationstrueGrantsToOrganizations
Grants To IndividualsfalseGrantsToIndividuals
Schedule J RequiredfalseScheduleJRequired
Tax Exempt BondsfalseTaxExemptBonds
Excess Benefit TransactionfalseExcessBenefitTransaction
Prior Excess Benefit TransactionfalsePriorExcessBenefitTransaction
Loan To Officer Or DQPfalseLoanToOfficerOrDQP
Grant To Related PersonfalseGrantToRelatedPerson
Bsnss Rltnshp With OrganizationfalseBsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family MemberfalseBsnssRltnshpThruFamilyMember
Officer Entity With Bsnss RltnshpfalseOfficerEntityWithBsnssRltnshp
Deductible Non Cash ContributionsfalseDeductibleNonCashContributions
Deductible Contributions Of ArtfalseDeductibleContributionsOfArt
TerminatedfalseTerminated
Partial LiquidationfalsePartialLiquidation
Disregarded EntityfalseDisregardedEntity
Related EntityfalseRelatedEntity
Related Org Controlled EntityfalseRelatedOrgControlledEntity
Transfers To Exempt Non Chrtbl OrgfalseTransfersToExemptNonChrtblOrg
Activities Conducted PartnershipfalseActivitiesConductedPartnership
Schedule O RequiredtrueScheduleORequired
Number Forms Transmitted With10962NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup WitholdingtrueComplianceWithBackupWitholding
Number Of Employees6NumberOfEmployees
Employment Tax Returns FiledtrueEmploymentTaxReturnsFiled
Unrelated Business IncomefalseUnrelatedBusinessIncome
Foreign Financial AccountfalseForeignFinancialAccount
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTrans
Taxable Party NotificationfalseTaxablePartyNotification
Non Deductible ContributionsfalseNonDeductibleContributions
Quid Pro Quo ContributionsfalseQuidProQuoContributions
Form8282 Property Disposed OffalseForm8282PropertyDisposedOf
Funds To Pay PremiumsfalseFundsToPayPremiums
Premiums PaidfalsePremiumsPaid
Form8899 FiledfalseForm8899Filed
Form1098 C FiledfalseForm1098CFiled
Indoor Tanning ServicesfalseIndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members5NbrVotingGoverningBodyMembers
Number Independent Voting Members5NumberIndependentVotingMembers
Family Or Business RelationshipfalseFamilyOrBusinessRelationship
Delegation Of Management DutiesfalseDelegationOfManagementDuties
Changes To Organizing DocsfalseChangesToOrganizingDocs
Material Diversion Or MisusefalseMaterialDiversionOrMisuse
Members Or StockholdersfalseMembersOrStockholders
Election Of Board MembersfalseElectionOfBoardMembers
Decisions Subject To ApprovalfalseDecisionsSubjectToApproval
Minutes Of Governing BodytrueMinutesOfGoverningBody
Minutes Of CommitteestrueMinutesOfCommittees
Officer Mailing AddressfalseOfficerMailingAddress
Local ChaptersfalseLocalChapters
Form990 Provided To Governing BodytrueForm990ProvidedToGoverningBody
Conflict Of Interest PolicytrueConflictOfInterestPolicy
Annual Disclosure Covered PersonstrueAnnualDisclosureCoveredPersons
Regular Monitoring EnforcementtrueRegularMonitoringEnforcement
Whistleblower PolicytrueWhistleblowerPolicy
Document Retention PolicytrueDocumentRetentionPolicy
Compensation Process CEOfalseCompensationProcessCEO
Compensation Process OtherfalseCompensationProcessOther
Investment In Joint VenturefalseInvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1AMERICAN FRIENDS OF KUPAT HAIRBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number7189728970TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line14415 14TH AVEAddressLine1
CityBROOKLYNCity
StateNYState
ZIP Code11219ZIPCode
FieldValueIRS element (for citing)
No Listed Persons CompensatedXNoListedPersonsCompensated

Form990 Part VII Section A Form990PartVIISectionA (5 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationOfficerOfficer
YOSEF FISHMAN
PRESIDENT25.00X000
CHAIM BRODT
DIRECTOR1.00X000
NOSSON RAAB
DIRECTOR2.00X000
CHAIM WILNER
VICE PRESIDE10.00000X
MOSHE PASKESZ
SECRETARY10.00000X
FieldValueIRS element (for citing)
Formers ListedfalseFormersListed
Total Comp GT150 KfalseTotalCompGT150K
Compensation From Other SourcesfalseCompensationFromOtherSources
All Other Contributions4064746AllOtherContributions
Total Contributions4064746TotalContributions

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column1552TotalRevenueColumn
Related Or Exempt Function Income1552RelatedOrExemptFunctionIncome

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column4066298TotalRevenueColumn
Related Or Exempt Function Income1552RelatedOrExemptFunctionIncome

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total280000Total
Program Services280000ProgramServices

Grants To Domestic Individuals GrantsToDomesticIndividuals

FieldValueIRS element (for citing)
Total720Total
Program Services720ProgramServices

Foreign Grants ForeignGrants

FieldValueIRS element (for citing)
Total2842400Total
Program Services2842400ProgramServices

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total49418Total
Management And General49418ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total3780Total
Management And General3780ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total7500Total
Management And General7500ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total9459Total
Management And General9459ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total379715Total
Fundraising379715Fundraising

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total459143Total
Management And General23911ManagementAndGeneral
Fundraising435232Fundraising

Occupancy Occupancy

FieldValueIRS element (for citing)
Total19036Total
Management And General19036ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total3423Total
Program Services3329ProgramServices
Fundraising94Fundraising

Insurance Insurance

FieldValueIRS element (for citing)
Total4313Total
Management And General4313ManagementAndGeneral

Other Expenses OtherExpenses

FieldValueIRS element (for citing)
DescriptionBANK CHARGESDescription
Total175Total
Management And General175ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total4059082Total
Program Services3126449ProgramServices
Management And General117592ManagementAndGeneral
Fundraising815041Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY319654BOY
EOY338067EOY

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

FieldValueIRS element (for citing)
BOY30BOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY319684BOY
EOY338067EOY

Unsecured Notes Loans Payable UnsecuredNotesLoansPayable

FieldValueIRS element (for citing)
BOY25581BOY
EOY39062EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY2314BOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY27895BOY
EOY39062EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY291789BOY
EOY299005EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY291789BOY
EOY299005EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY319684BOY
EOY338067EOY
FieldValueIRS element (for citing)
Reconcilation Revenue Expenses7216ReconcilationRevenueExpenses
Method Of Accounting CashXMethodOfAccountingCash
Accountant Compile Or ReviewfalseAccountantCompileOrReview
FS AuditedfalseFSAudited
Federal Grant Audit RequiredfalseFederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Publicly Supported Org170b1 AviXPubliclySupportedOrg170b1Avi

Gifts Grants Contrib Received170 GiftsGrantsContribReceived170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years5208056CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years6296611CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years4767453CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year4342682CurrentTaxYearMinus1Year
Current Tax Year4064746CurrentTaxYear
Total24679548Total

Total170 Total170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years5208056CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years6296611CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years4767453CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year4342682CurrentTaxYearMinus1Year
Current Tax Year4064746CurrentTaxYear
Total24679548Total
FieldValueIRS element (for citing)
Public Support Total17024679548PublicSupportTotal170

Gross Investment Income170 GrossInvestmentIncome170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years8528CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years2152CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years1500CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year866CurrentTaxYearMinus1Year
Current Tax Year1552CurrentTaxYear
Total14598Total
FieldValueIRS element (for citing)
Total Support24694146TotalSupport
Gross Receipts From Admissions Etc1552GrossReceiptsFromAdmissionsEtc
Public Support Pertcentage1700.99940PublicSupportPertcentage170
Public Support Pertcent Prior Year0.96200PublicSupportPertcentPriorYear
Thirty Three Percnt Tests CY170XThirtyThreePercntTestsCY170

Schedule F IRS990ScheduleF

Grants To Orgs Outside US GrantsToOrgsOutsideUS (4 entries)

RegionRegionPurpose Of GrantPurposeOfGrantAmount Of Cash GrantAmountOfCashGrantManner Of Cash DisbursementMannerOfCashDisbursement
MIDDLE EASTTO FURTHER EXEM. PUR2550000WIRE
MIDDLE EASTTO FURTHER EXEM. PUR25000WIRE
MIDDLE EASTTO FURTHER EXEM. PUR13000WIRE
MIDDLE EASTTO FURTHER EXEM. PUR250000WIRE
FieldValueIRS element (for citing)
Total Number Of501c3 Orgs3TotalNumberOf501c3Orgs
Total Number Of Other Orgs1TotalNumberOfOtherOrgs
Transfer To Foreign CorpfalseTransferToForeignCorp
Interest In Foreign TrustfalseInterestInForeignTrust
Own Foreign CorpfalseOwnForeignCorp
Passive Foreign Invest CofalsePassiveForeignInvestCo
Foreign PartnershipfalseForeignPartnership
Boycott CountriesfalseBoycottCountries

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Records MaintainedtrueRecordsMaintained

Recipient Table RecipientTable (2 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEIN Of RecipientEINOfRecipientIRC SectionIRCSectionAmount Of Cash GrantAmountOfCashGrantPurpose Of GrantPurposeOfGrant
MESAMCHE LEV
1364 53RD STREETBROOKLYNNY11219222453421501 C3250000TO FURTHER EXEM. PUR
TZIDKAS ERETZ HAKODESH
1315 43RD STREETBROOKLYNNY1121927045212130000TO FURTHER EXEM. PUR
FieldValueIRS element (for citing)
Total Nbr Of501 C3 And Govt Grants1TotalNbrOf501C3AndGovtGrants
Total Nbr Of Other Organizations1TotalNbrOfOtherOrganizations

Form990 Schedule I Part IV Form990ScheduleIPartIV

FieldValueIRS element (for citing)
IdentifierPROCEDURES FOR MONITORING THE USE OF GRANT FUNDS INSIDE THE UNITED STATESIdentifier
Return ReferenceSCHEDULE I, PAGE 1, PART I, LINE 2ReturnReference
ExplanationTHE ORGANIZATION MONITORS AND REVIEWS GRANTEES TO ENSURE THAT THEY OPERATE AND DISTRIBUTE FUNDS IN ACCORDANCE WITH THEIR OBJECTIVES.Explanation

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (4 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
ORGANIZATION'S MISSIONFORM 990 - ORGANIZATION'S MISSIONTO RAISE FUNDS FOR DISTRIBUTION TO INSTITUTIONS ORGANIZED AND OPERATED EXCLUSIVELY FOR RELIGIOUS, CHARITABLE AND EDUCATIONAL PURPOSES IN THE UNITED STATES AND ISRAEL WITH A VIEW TOWARD PROVIDING AID, ASSISTANCE AND SUPPORT TO NEEDY AND INDIGENT INDIVIDUALS IN ISRAEL AND THE UNITED STATES.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990FORM 990, PAGE 6, PART VI, LINE 11BTHE TAX RETURN PREPARER SENDS THE BOARD OF DIRECTORS A DRAFT COPY OF THE COMPLETE TAX RETURN FOR REVIEW AND COMMENTS. AFTER THE BOARD OF DIRECTORS APPROVES THE RETURN THEY NOTIFY THE TAX RETURN PREPARER AND A FINAL VERSION OF THE TAX RETURN IS SENT TO THE EXECUTIVE DIRECTOR. THE EXECUTIVE DIRECTOR THEN SIGNS THE E-FILE AUTHORIZATION FORM AND RETURNS IT TO THE TAX RETURN PREPARER. THE PREPARER THEN E-FILES THE RETURN.
ENFORCEMENT OF CONFLICTS POLICYFORM 990, PAGE 6, PART VI, LINE 12CTHE BOARD OF DIRECTORS ARE REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICT OF INTEREST. FAILURE TO DISCLOSE A POTENTIAL CONFLICT OF INTEREST MAY RESULT IN DISCIPLINARY ACTION UP TO AND INCLUDING TERMINATION.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATIONFORM 990, PAGE 6, PART VI, LINE 19UPON REQUEST THE PUBLIC MAY VIEW THE ORGANIZATION'S GOVERNING DOCUMENTS AND RELATED DOCUMENTS AT THE ADDRESS LOCATED ON PAGE 1 OF THIS FORM.