Beruflich Dokumente
Kultur Dokumente
A For the 2004 calendar vear. or tax veer beqinninct . 2004, and ending
B Check if applicable D Employer Identification number
Please
Address change use IRS IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 34-1962043
label or
Name change
pdnt or 86578 ******AUTO**5-DIGIT 44708 Telephone number
Initial return type . PFHOF ENSHRINEE ASSISTANCE
fee 330-456-8207
Final return Specific C/0 PRO FOOTBALL OF FAME P157 R
Amended return !nstruc" 2121 GEORGE HALAS DR NW B 13
F Group Exemption
CANTODT OH 44708-2699 Number
0 Section 501(cXa~ organizations and 4947(a1(1) nonexempt charitable trusts G Accounting method : El Cash N Accrual
must attach a competed Schedule A (Form 990 or 990-E4. Others eci ) 1,
H Check 0, X if the organization is not
I Web site : - N/A required to a ach Schedule B (Form 990,
990 EZ , or 990 -Op).
J Organization type (check only one) - X 501(c) ( 3 ) -4 (insert no.) 4947(a)(1) or 527
K Check 1, if the organization's gross receipts are normally not more than $25,000 . The organization need not file a return with the IRS ;
but if the organization received a Form 990 Package in the mail, it should file a return without financial data . Some states require a
complete return .
L Add lines 5b, 6b, and 7b, to line 9 to determine gross receipts ; if $100,000 or more, file Form 990
instead of Form 990-EZ 11~ $ 30,692 .
~a'A1 Revenue, Exp enses, and Chan ges in Net Assets or Fund Balances see instructions)
1 Contributions, gifts, grants, and similar amounts received . 1 30 , 692 .
2 Program service revenue including government fees and contracts . 2
3 Membership dues and assessments . ... .. .. 3
4 Investment income 4
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 (line 5a less line Sb) (attach schedule) . 5e
w 6 Special events and activities (attach schedule) . If any amount is from gaming, check here
e
a Gross revenue (not including $ of contributions
e reported on line 1) 6a
b Less : direct expenses other than fundraising expenses . .. 6b
c Net income or (loss) from special events and activities (line 6a less line 6b) .. .. 6c
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 (line 7a less line 7b) . . .. 7c
8 Other revenue (describe ~r% ) 8
9 Total revenu add IM 2r r , 7c, nil 8 ~ 9 30 , 692 .
10 Grants and si if amounts paid (attach sc 1e) .. 10
p E 11 Benefits paid r fo~Aj r ,bfr!2 ~ O .. . , . . . ,. .. 11
2a0~
X 12 Salaries, oth r~ mpensaion, and emp oy nefits 12
e 13 Professional es -ethrei ~ n dent contractors , . 13 3, 250 .
S 14 Occupancy, r nt, u li s nte 14
ff
Es 15 Printing, ubl .. ,. . 15
U ;, 16 Other expenses (describe " SEE STATEMENT 1 ) 16 5,470 .
17 Total exp enses (add lines 10 through 16) . ~ 17 8,720 .
18 Excess or (deficit) for the year (line 9 less line 17) ... 18 21,972 .
N s 19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end-of-year
U EE figure reported on prior year's return) . , 19 92,499 .
T t 20 Other changes in net assets or fund balances (attach explanation) 20
5 21 Net assets or fund balances at end of ear combine lines 18 throug h 20 ,. .. 0. 21 114 , 471 .
P+"ciO It Balance Sheets - If Total assets on line 25, column (B) are $250,000 or more, file Form 990 instead of Form 990-EZ .
(See Instructions) nnmg of year (B) End of year
22 Cash, savings, and investments 57,050 . 1 22 1 105,885 .
23 Land and buildings ...
24 Other assets (describe I- SEE STATEMENT 2 37,44
25 Total assets
26 Total liabilities (describe 1, SEE STATEMENT 3 ) 0
27 Net assets or fund balances (line 27 of column (B) must agree with line 21) 114,471 .
-- "
BAA For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. TEEA0803L 01107/05 Form 990-EZ (2004)
\_\,r
~(
Form 990-EZ 2004 PFHOF ENSHRINEES ASSISTANCE FOUNDATION 34-1962043 Pa ge 2
07Wrt its ~ Statement of Pro g ram Service Accom p lishments see Instructions) Expenses
What is the organization's primary exempt purpose? (Required for 501(c)(3)
Describe what was achieved in carrying out me organization s exempt p urposes, in a clear an concise manner, and (4) organizations and
describe the services provided, the number of persons benefited, or other relevant information for each 4947(a)(1) trusts; optional
p rog ram title . for others .
28
----------------------------------------------------
----------------------------------------------------
Grants $ 28a
29
----------------------------------------------------
----------------------------------------------------
Grants $ 29a
30
----------------------------------------------------
----------------------------------------------------
Grants $ 30a
31 Other program services schedule Grants $ 31a
32 Total program service e > (add lines 28a through 31a . ~ 32
'aAList of Offices 'Ctors, Trustees, and Key. Em to ees List each one even if not comp ensated . See Instructions .)
(B) Title and average hours (C) Compensation (If (D) Contributions to (E) Expense account
(A) Name and address per week devoted not paid, enter -0-.) employee benefit plans and and other allowances
to p osition deferred com p ensation
0. 0. 0.
Part V I Other Information (Note the attachment requirement in the instructions) SEE STATEMENT 6 No
33 Did the organization engage in any activity not previously reported to the IRS? If 'Yes,' attach a detailed description
of each activity .. .. X
34 Were any changes made to the organizing or governing documents but not reported to the IRS? If 'Yes,' attach a conformed copy of the changes X
35 If the organization had income from business activities, such as those reported on lines 2, 6, and 7 (among others), but not reported on Form 990-T, attach a
statement explaining your reason for not reporting the income on Form 990-T.
a Did the organization have unrelated business gross income of $1,000 or more or 6033(e) notice, reporting, and proxy tax requirements? .. . .. X
b If 'Yes,' has it filed a tax return on Form 990-T for this year? . . . . . .. , , .... , , A
36 Was there a liquidation, dissolution, termination, or substantial contraction during the year? (If 'Yes,' attach a statement ) X
37a Enter amount of political expenditures, direct or indirect, as described in the instructions 0- 1 37al 0.
b Did the organization file Form 1120-POL for this year? . . . . .. . .. . , ,,,, ., X
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 unpaid at the start of the period covered by this return? .. ..... . ... ... X
b If 'Yes,' attach the schedule specified in the line 38 instructions and enter the amount involved .. , , 38b N/1
39 501(c)(7) organizations Enter : a Initiation fees and capital contributions included on brie 9 39a N/1
b Gross receipts, included on line 9, for public use of club facilities . . I 39b N/p
40a 501(c)(3) organizations Enter : Amount of tax imposed on the organization during the year under :
section 4911 . 0 . ; section 4912 0- 0 . ; section 4955 ~ 0.
b 501(c)(3) and (4) organizations. Did the organization engage m any section 4958 excess benefit transaction during the year or did it become aware of an excess
benefit transaction from a prior year? If 'Yes,' attach an explanation ... . ,. . . . ... , X
c Amount of tax imposed on organization managers or disqualified persons during the year under 4912, 4955, and 4958 . .
d Enter : Amount of tax on line 40c, above, reimbursed by the organiz
41 List the states with which a copy of this return is filed 0, OHIO
42 The books are m care of - JOHN BANKERT
Located at - 2121 GEORGE HALAS DRIVE NW, CANTON
43 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ i
and enter the amou t of tax-exempt interest received or accrued du
Under penalties f erjury, I declare that I have examine this return, including a
' true, correct, a mplete D9clarahon of pryparer (yt~r fhaq officer) is based
ease
Sign
Here Sqnahue of officer
Paid Prepares
signature
Pre- 0- 4~2~ - -,
p S (or ~qESTEL, LONG & SCHRADE, INC
Firm's name
yours
Use t 116 CLEVELAND AVE . N . W . , #52
Only aP+a'a"a CANTON OH 44702
BAA TEEA0812L
Organization Exempt Under OMB No . 15450047
NONE
(a) Name and address of each independent contractor paid more than $50,000 (b) Type of service I (c) Compensation
NONE
TEEA0401L 07122/04
Schedule -A Form 990 or 990-E 2004 PFHOF ENSHRINEES ASSISTANCE FOUNDATION 34-1962043 Pa e 2
1 During the year, has the organization attempted to influence national, state, or local legislation, including any attempt
to influence public opinion on a legislative matter or referendum? If 'Yes,' enter the total expenses paid
or incurred in connection with the lobbying activities . . . 01, $ N/A
(Must equal amounts on line 38, Part VI-A, or line i of Part VI-B .) 1 X
Organizations that made an election under section 501(h) by fling Form 5768 must complete Part VI-A . Other
organizations checking 'Yes' must complete Part VI-13 AND attach a statement giving a detailed description of the
lobbying activities.
2 During the year, has the organization, either directly or indirectly, engaged in any of the following acts with any
substantial contributors, trustees, directors, officers, creators, key employees, or members of their families, or with any
taxable organization with which any such person is affiliated as an officer, director, trustee, majority owner, or principal
beneficiary? (If the answer to any question is 'Yes, ' attach a detailed statement explaining the transactions )
d Payment of compensation (or payment or reimbursement of expenses if more than $1,000)? 1 2dl I X
3a Do you make grants for scholarships, fellowships, student loans, etc? (If 'Yes ' attach an
explanation of how you determine that recipients qualify to receive payments . .... 3a X
b Do you have a section 403(b) annuity plan for your employees? . . 3b X
4a Did you maintain any separate account for participating donors where donors have the right to provide advice
on the use or distribution of funds? 4a X
b Do you provide credit counseling, debt management, credit repair, or debt negotiation services? I 4bl ~ X
The organization is not a private foundation because it is : (Please check only ONE applicable box .)
5 A church, convention of churches, or association of churches . Section 170(b)(1)(A)(i) .
6 A school . Section 170(b)(1)(A)(iQ . (Also complete Part V.)
7 A hospital or a cooperative hospital service organization . Section 170(b)(1)(A)(iii) .
8 A Federal, state, or local government or governmental unit . Section 170(b)(1)(A)(v) .
9 u A medical research organization operated in conjunction with a hospital . Section 170(b)(1)(A)(m) . Enter the hospital's name, city,
and state
10 r] An organization operated for the benefit of a college or university owned or operated by a governmental unit . Section 170(b)(1)(A)(iv) .
(Also complete the Support Schedule in Part IV-A.)
11 a a An organization that normally receives a substantial part of its support from a governmental unit or from the general public .
Section 170(b)(1)(A)(vi) . (Also complete the Support Schedule in Part IV-A .)
11 b ~ A community trust Section 170(b)(1)(A)(vi) . (Also complete the Support Schedule m Part IV-A .)
12 F-] An organization that normally receives : (1) more than 33-113°/. of its support from contributions, membership fees, and gross receipts
from activities related to its charitable, etc, functions - subject to certain exceptions, and (2) no more than 33113°/. of its support
from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the
organization after June 30, 1975 . See section 509(a)(2) . (Also complete the Support Schedule in Part IV-A .)
13 W An organization that is not controlled by any disqualified persons (other than foundation managers) and supports organizations
described in : (1) lines 5 through 12 above ; or (2) section 501(c)(4), (5), or (6), if they meet the test of section 509(a)(2) . (See
section 509(a)(3) .)
Provide the following information about the supported organizations . (See instructions
14 n An organization organized and operated to test for public safety . Section 509(a)(4) . (See instructions .)
BAA TEEA0402L 07127/04 Schedule A (Form 990 or Form 990-EZ) 2004
Schedule A Form 990 or 990-E 2004 PFHOF ENSHRINEES ASSISTANCE FOUNDATIO 34-1962043 Pa ge 3
Pott IVA Support Schedule (Complete only if you checked a box on line 10, 11, or 12.) Use cashmethodoJaccounting.
Note: You ma use the worksheet m the Instructions for convertor from the accrual to the cash method of accounting
Calendar ear (or fiscal ear (a) (b (c) (d ) (e)
beginningin) . y . ~ 2003 2b2 2b61 2000 Total
15 Gifts, grants, and contributions
received . (Do not include
unusual rants . See line 28 . N/A
16 Membershi p fees received
29 Does the organization have a racially nondiscriminatory policy toward students by statement m its charter, bylaws,
other governing instrument, or in a resolution of its governing body? . 29
30 Does the organization include a statement of its racially nondiscriminatory policy toward students in all its brochures,
catalogues, and other written communications with the public dealing with student admissions, programs,
and scholarships? 30
31 Has the organization publicized its racially nondiscriminatory policy through newspaper or broadcast media during
the period of solicitation for students, or during the registration period if it has no solicitation program, in a way that
makes the policy known to all parts of the general community it serves? . . .. .... .... . . . ...... . .. . . .. .. 31
If 'Yes,' please describe ; if 'No,' please explain . (If you need more space, attach a separate statement .)
---------------------------------------------------------
---------------------------------------------------------
---------------------------------------------------------
---------------------------------------------------------
32 Does the organization maintain the following :
a Records indicating the racial composition of the student body, faculty, and administrative staff? 32a
b Records documenting that scholarships and other financial assistance are awarded on a racially
nondiscriminatory basis? 32b
c Cop ies of all catalogues, brochures, announcements, and other written communications to the public dealing
with student admissions, programs, and scholarships? . . .. .. . .. .. 32c
d Copies of all material used by the organization or on its behalf to solicit contributions? . . . . 32d
If you answered 'No' to any of the above, please explain . (If you need more space, attach a separate statement.)
--------------------------------------------------------
--------------------------------------------------------
b Admissions policies?
g Athletic programs?
If you answered 'Yes' to any of the above, please explain . (If you need more space, attach a separate statement .)
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--------------------------------------------------------
--------------------------------------------------------
34a Does the organization receive any financial aid or assistance from a governmental agency2 . , , 34a
b Has the organization's right to such aid ever been revoked or suspended? . . . . . , 3qb
If you answered 'Yes' to either 34a or b, please explain using an attached statement.
35 Does the organization certify that it has coin plied with the applicable requirements of
sections 4.01 through 4.05 of Rev Proc 75-50, 1975-2 C.B . 587, covering racial
nondiscrimination? If 'No,' attach an ex planation . 35
BAA TEEA0404L 07f23/04 Schedule A (Form 990 or 9
Schedule ,A Form 990 or 990-E 2004 PFHOF ENSHRINEES ASSISTANCE FOUNDATI 34-1962043 Page 5
P4i~ VIA Lobbying Expenditures by Electing Public Charities see instructions .)
(To be completed ONLY by an eligible organization that filed Form 5768) N/A
;heck 0, a U if the organization belongs to an affiliated group . Check 0- b I I if yo checked 'a' and 'limited control' p rovisions app ly .
45 Lobbying nontaxable
amount
47 Total lobbying
48 Grassroots non-
taxable amount
50 Grassroots lobbying
expenditures
Pmt WS Lobbying Activity by Nonelecting Public Charities
(For reporting only by organizations that did not complete Part VI-A) (See instructions .) N/A
During the year, did the organization attempt to influence national, state or local legislation, including any
attempt to influence public opinion on a legislative matter or referendum, through the use of: Yes No Amount
a Volunteers .. ,. , , , ., .,
b
Paid staff or management (Include compensation in expenses reported on lines c through h .). . . .
c
Media advertisements
d
Mailings to members, legislators, or the public ...
e
Publications, or published or broadcast statements ...
f
Grants to other organizations for lobbying purposes ..
g
Direct contact with legislators, their staffs, government officials, or a legislative body
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any other means
i Total lobbying expenditures (add lines c through h .) . . . . . ..
If 'Yes' to any of the above, also attach a statement giving a detailed description of the lobbying activities .
BAA Schedule A (Form 990 or 990-EZ) 2004
TEEA0405L 07/23104
Schedule A Form 990 or 990-E 2004 PFHOF ENSHRINEES ASSISTANCE FOUNDAT 34-1962043 Page 6
11Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations (see instructions)
51 Did the reporting organization directly or indirectly engage in any of the following with any other organization described in section 501(c)
of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
a Transfers from the reporting organization to a noncharitable exempt organization of : Yes No
(i)Cash . . . . . . . . .. ... 51 a i X
(ii)Other assets ........ ....... . a ii X
b Other transactions :
(i)Sales or exchanges of assets with a noncharitable exempt organization b i X
(ii)Purchases of assets from a noncharitable exempt organization b ii X
(iii)Rental of facilities, equipment, or other assets .. . . . ........ ... .. .... ..... b iii X
(iv) Reimbursement arrangements .. ... ............... .. ..... .. . b iv X
(v)Loans or loan guarantees . ... ....... . . . .......... . . b v) X
(vi)Performance of services or membership or fundraising solicitations . . . b vi) X
c Sharing of facilities, equipment, marling lists, other assets, or paid employees c X
d If the answer to any of the above is 'Yes,' complete the following schedule . Column (b) should always show the fair market value of
the goods, other assets, or services given by the re ortin or~ganization . If the organization received less than fair market value in
an transaction or sharing arrangement, show in column ~d) the value of the goods, other assets, or services received :
(a) (b) (c) (d)
Line no . Amount involved Name of nonchantable exempt organization Description of transfers, transactions, and sharing arrangements
N/
52a Is the organization directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527? . . . ~ ~ Yes X~ No
TEEA0406L 11x29/04
2004 FEDERAL STATEMENTS PAGE 1
PFHOF ENSHRINEES ASSISTANCE FOUNDATION 34-19620431
STATEMENT 1
FORM 990-EZ, PART I, LINE 16
OTHER EXPENSES
AMORTIZATION $ 4,732 .
INSURANCE . . . . ... . ... .. ... 558 .
MISCELLANEOUS 180 .
TOTAL 5,470 .
STATEMENT 2
FORM 990-EZ, PART II, LINE 24
OTHER ASSETS
BEGINNING ENDING
ACCOUNTS RECEIVABLE. $ 23,254 . $ 1,380 .
NET INTANGIBLE ASSETS 14,195 . 9,464 .
PREPAID EXPENSES AND DEFERRED CHARGES 0. 492 .
TOTAL 37,9 . 1,336 .
STATEMENT 3
FORM 990-EZ, PART II, LINE 26
TOTAL LIABILITIES
BEGINNING ENDING
ACCOUNTS PAYABLE AND ACCRUED EXPENSES . . . . $ 2 , 000 . $ 2 750 .
TOTAL 2,000 . 2,`T50 .
STATEMENT 4
FORM 990-EZ, PART III
ORGANIZATION'S PRIMARY EXEMPT PURPOSE
THE PFHOF ENSHRINEES ASSISTANCE FOUNDATION IS AN ORGANIZATION DEDICATED TO
PROVIDING FINANCIAL ASSISTANCE T0, OR FOR THE BENEFIT OF, POOR, NEEDY OR
DISTRESSED INDIVIDUALS WHO ARE ENSHRINED IN THE PRO FOOTBALL HALL OF FAME; AND/OR
THEIR POOR, NEEDY OR DISTRESSED FAMILY MEMBERS .
STATEMENT 5
FORM 990-EZ, PART IV
LIST OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES
STATEMENT 5 (CONTINUED)
FORM 990-EZ, PART IV
LIST OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES
TOTAL 0 . ~--0 . 0.
STATEMENT 6
FORM 990-EZ, PART V
REGARDING TRANSFERS ASSOCIATED WITH PERSONAL BENEFIT CONTRACTS
(A) DID THE ORGANIZATION, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY OR
INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT? NO
(B) DID THE ORGANIZATION, DURING THE YEAR, PAY PREMIUMS, DIRECTLY OR
INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT? ..... NO
91
_~.nr X68 (Rev 12-2004) r Page
e If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part 11 and check this box . . " ~J
Note. Only complete Part II if you have already been granted an automatic 3-month extension on a previously fled Form 8868 .
9 If you are filing for an Automatic 3-Month Extension, complete only Part I (on page 1) .
RMIN Additional not automatic 3-Month Extension of Time-Must File Origin al and One Co
Type or Name of Exempt Organization Employer identification number
print PFHOF ENSHRINEES ASSISTANCE FOUNDATION + 34 : 1962043
File by the Number, street, and room or suite no If a P O box, see instructions. For IRS use only
extended 2121 GEORGE HALAS DR NW
due date for
filing the City, town or post office, state, and ZIP code For a foreign address, see instructions
return See
instructions CANTON, OH 44708
Check type of return to be filed (File a separate application for each return) :
JO Form 990 El Form 990-T (sec . 401(a) or 408(a) trust) El Form 5227
D Form 990-BL El Form 990-T (trust other than above) D Form 6069
Form 990-EZ [] Form 1041-A El Form 8870
Form 990-PF El Form 4720
STOP: Do not complete Part II it you were not already granted an automatic 3-month extension on a previously filed Form 8868 .
The books are in the care of " _JOHN------------------------------------------------------------------------------
BANKERT
TefephoneNo . " (__330__)----- ____456-82p7 ._ . . . . . _ FAX No . " 330 .__)_ .____ . ._45fr8175_ ._______
~ If the organization does not have an office or place of business in the United States, check this box . . . . . . " D
~ If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) If this is
for the whole group, check this box " 0 . If it is for part of the group, check this box " Ej and attach a list with the
names and EINs of all members the extension is for.
4 I request an additional 3-month extension of time until _ ._ . . NOVEMBER 15 20 .9§. .
5 For calendar year M4_, or other tax year beginning ------------------------
------ , 20.___ , andending ------------------------ , 20. . . . .
6 If this tax year is for less than 12 months, check reason : D Initial return D Final return D Change in accounting period
7 State in detail why you need the extension AD DITIONAL,TtME IS REQUIRED IN ORDER TO OBTAIN THE
--INFORMATION NECESSARY
---------- --------------- TO FILE A COMPLETE AND ACCURATE RETURN .
---------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------- - -----
8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 069, Ar1t6~I ~x, le ------ -----------------------------
any
nonrefundable credits . See instructions . . . . . . . ~ . . , . . .
b If this application is for Form 990-PF, 990-T, 4720, or 6069, ent re,~yq~b~eredits and i ated
tax payments made . Include any prior year overpayment allo ~Q as ~~~kdl~ d2~a paid
previously with Form 8868 . . . . . . . . . . . . ~ . . $
c Balance Due . Subtract line 8b from line 8a . Include your payme t wit tol if red, eposit
with FTD coupon or, if re q uired, b usin g EFTPS Electronic Feder ~~ instr tions. $
Signature and Verification
Under penalties of wry, I declare that I have examined this form, Including accompanying schedules and statements, and to the best of my knowledge and belief,
it Is true, correct rid omplete, and thayi am authorized to prepare this form
/ /' > / n - 7
Title 10o Date t
ay
Director Date
Alternate Mailing Address - Enter the address if you want the copy of this application for an add' 3-month extension
returned to an address different than the one entered above. 01&~44,
Name "'V APpR
MESTEL, LONG & SCHRADE, INC. ~~FQ
;
Type or Number and street (include suite, room, or apt, no .) or a P.O . box number "(7
92005
print 116 CLEVELAND AVE NW, SUITE 525
City or town, province or state, and country (including postal or ZIP code) _ v°~/SS
CANTON, off 44702 ~~NpRpC Fo . Ran>_
Form CifM4ft4' 12-2004)