U.S. Income Tax Return for an S Corporation. OMB No Form

Transcription

1 Sign Here 112S Paid Preparer Use Only U.S. Income Tax Return for an S Corporation OMB No Form Do not file this form unless the corporation has filed or is attaching Form 2553 to elect to e an S corporation. 212 Department of the Treasury Internal Revenue Service Information aout Form 112S and its separate instructions is at For calendar year 212 or tax year eginning, 212, ending, 2 A S election effective date Name D Employer identification numer B TYPE Business activity code Numer, street, and room or suite no. If a P.O. ox, see instructions. E Date incorporated numer (see instructions) OR PRINT 464 LAKELAND AVE NORTH City or town, state, and ZIP code F Total assets (see instructions) C Check if Sch. M-3 attached ROBBINSDALE MN $ 44,655 G Is the corporation electing to e an S corporation eginning with this tax year? Yes X No If "Yes," attach Form 2553 if not already filed H Check if: (1) Final return (2) Name change (3) Address change (4) Amended return (5) S election termination or revocation I Enter the numer of shareholders who were shareholders during any part of the tax year Caution. Include only trade or usiness income and expenses on lines 1a through 21. See the instructions for more information. 1a Gross receipts or sales a 429,94 Returns and allowances c Balance. Sutract line 1 from line 1a c 429,94 2 Cost of goods sold (attach Form 1125-A) Gross profit. Sutract line 2 from line 1c ,94 4 Net gain (loss) from Form 4797, line 17 (attach Form 4797) Other income (loss) (see instructions - attach statement) Total income (loss). Add lines 3 through ,94 7 Compensation of officers , 8 Salaries and wages (less employment credits) ,182 9 Repairs and maintenance ,52 1 Bad dets Rents , Taxes and licenses ATT_STL , Interest , Depreciation not claimed on Form 1125-A or elsewhere on return (attach Form 4562) , Depletion (Do not deduct oil and gas depletion.) Advertising , Pension, profit-sharing, etc., plans Employee enefit programs Other deductions (attach statement) Statement # ,242 2 Total deductions. Add lines 7 through , Ordinary usiness income (loss). Sutract line 2 from line ,29 22 a Excess net passive income or LIFO recapture tax (see instructions)... 22a Tax from Schedule D (Form 112S) c Add lines 22a and 22 (see instructions for additional taxes) c 23 a 212 estimated tax payments and 211 overpayment credited to a Tax deposited with Form c Credit for federal tax paid on fuels (attach Form 4136) c d Add lines 23a through 23c d 24 Estimated tax penalty (see instructions). Check if Form 222 is attached Amount owed. If line 23d is smaller than the total of lines 22c and 24, enter amount owed Overpayment. If line 23d is larger than the total of lines 22c and 24, enter amount overpaid Enter amount from line 26 Credited to 213 estimated tax Refunded 27 Income (see instructions for limitations) Deductions Tax and Payments Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the est of my knowledge and elief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is ased on all information of which preparer has any knowledge. For Paperwork Reduction Act Notice, see separate instructions. EEA ROBIN CENTER CHIROPRACTIC ALEX CHERNYAVSKY PRESIDENT May the IRS discuss this return Signature of officer Date Title Print/Type preparer's name Preparer's signature Date Check if PTIN self-employed Firm's name Firm's EIN Firm's address Phone no. with the preparer shown elow (see instructions)? Yes No Laurel St John CPA P Aercromie Accounting 7582 Currell Blvd Ste 211 Woodury MN (651) X Form 112S (212)

2 Schedule B ROBIN CENTER CHIROPRACTIC Other Information (see instructions) X Form 112S (212) Page 2 1 Check accounting method: a Cash Accrual Yes No c Other (specify) 2 See the instructions and enter the: a Business activity SERVICES Product or service 3 At any time during the tax year, was any shareholder of the corporation a disregarded entity, a trust, an estate, or a nominee or similar person? 4 At the end of the tax year, did the corporation: a Own directly 2% or more, or own, directly or indirectly, 5% or more of the total stock issued and outstanding of any foreign or domestic corporation? For rules of constructive ownership, see instructions. If "Yes," complete (i) through (v) elow CHIROPRACTIC X (i) Name of Corporation (ii) Employer Identification Numer (iii) Country of (iv) Percentage of Stock (if any) Incorporation Owned (v) If Percentage in (iv) is 1%, Enter the Date (if any) a Qualified Suchapter S Susidiary Election Was Made Own directly an interest of 2% or more, or own, directly or indirectly, an interest of 5% or more in the profit, loss, or capital in any foreign or domestic partnership (including an entity treated as a partnership) or in the eneficial interest of a trust? For rules of constructive ownership, see instructions. If "Yes," complete (i) through (v) elow X (i) Name of Entity (ii) Employer Identification Numer (iv) Country of (v) Maximum Percentage Owned in Profit, (iii) Type of Entity (if any) Organization Loss, or Capital 5a a a EEA At the end of the tax year, did the corporation have any outstanding shares of restricted stock? If "Yes," complete lines (i) and (ii) elow (i) Total shares of restricted stock (ii) Total shares of non-restricted stock At the end of the tax year, did the corporation have any outstanding stock options, warrants, or similar instruments? If "Yes," complete lines (i) and (ii) elow. (i) Total shares of stock outstanding at the end of the tax year (ii) Total shares of stock outstanding if all instruments were executed Has this corporation filed, or is it required to file, Form 8918, Material Advisor Disclosure Statement, to provide information on any reportale transaction? Check this ox if the corporation issued pulicly offered det instruments with original issue discount If checked, the corporation may have to file Form 8281, Information Return for Pulicly Offered Original Issue Discount Instruments. If the corporation: (a) was a C corporation efore it elected to e an S corporation or the corporation acquired an asset with a asis determined y reference to the asis of the asset (or the asis of any other property) in the hands of a C corporation and () has net unrealized uilt-in gain in excess of the net recognized uilt-in gain from prior years, enter the net unrealized uilt-in gain reduced y net recognized uilt-in gain from prior years (see instructions) $ Enter the accumulated earnings and profits of the corporation at the end of the tax year. $ Does the corporation satisfy oth of the following conditions? The corporation's total receipts (see instructions) for the tax year were less than $25, The corporation's total assets at the end of the tax year were less than $25, If "Yes," the corporation is not required to complete Schedules L and M-1. During the tax year, did the corporation have any non-shareholder det that was canceled, was forgiven, or had the terms modified so as to reduce the principal amount of the det? If "Yes," enter the amount of principal reduction $ During the tax year, was a qualified suchapter S susidiary election terminated or revoked? If "Yes," see instructions Did the corporation make any payments in 212 that would require it to file Form(s) 199? If "Yes," did the corporation file or will it file all required Forms 199? X Form 112S (212)

3 Alternative ROBIN CENTER CHIROPRACTIC Schedule K Shareholders' Pro Rata Share Items Total amount 1 Ordinary usiness income (loss) (page 1, line 21) ,29 2 Net rental real estate income (loss) (attach Form 8825) ,54 Form 112S (212) Page 3 Income (Loss) Deductions Credits Foreign Transaction (AMT) Items Minimum Tax Items Affecting Shareholder Basis EEA a Other gross rental income (loss) 3a Expenses from other rental activities (attach statement) c Other net rental income (loss). Sutract line 3 from line 3a c 4 Interest income Dividends: a Ordinary dividends a Qualified dividends Royalties Net short-term capital gain (loss) (attach Schedule D (Form 112S)) a Net long-term capital gain (loss) (attach Schedule D (Form 112S)) a Collectiles (28%) gain (loss) c Unrecaptured section 125 gain (attach statement) c 9 Net section 1231 gain (loss) (attach Form 4797) Other income (loss) (see instructions).. Type 1 11 Section 179 deduction (attach Form 4562) a Charitale contriutions a Investment interest expense c Section 59(e)(2) expenditures (1) Type (2) Amount 12c(2) d Other deductions (see instructions)... Type 12d 13a Low-income housing credit (section 42(j)(5)) a Low-income housing credit (other) c Qualified rehailitation expenditures (rental real estate) (attach Form 3468) c d Other rental real estate credits (see instructions).. Type 13d e Other rental credits (see instructions) Type 13e f Alcohol and cellulosic iofuel fuels credit (attach Form 6478) f g Other credits (see instructions) Type 13g 14a Name of country or U.S. possession Gross income from all sources c Gross income sourced at shareholder level c Foreign gross income sourced at corporate level d Passive category d e General category e f Other (attach statement) f Deductions allocated and apportioned at shareholder level g Interest expense g h Other h Deductions allocated and apportioned at corporate level to foreign source income i Passive category i j General category j k Other (attach statement) k Other information l Total foreign taxes (check one): Paid Accrued l m Reduction in taxes availale for credit (attach statement) m n Other foreign tax information (attach statement) 15a Post-1986 depreciation adjustment a Adjusted gain or loss c Depletion (other than oil and gas) c d Oil, gas, and geothermal properties-gross income d e Oil, gas, and geothermal properties-deductions e f Other AMT items (attach statement) f 16a Tax-exempt interest income a Other tax-exempt income c Nondeductile expenses c d Distriutions (attach statement if required) (see instructions) d e Repayment of loans from shareholders e 2,168 (1,55) 3,83 19,247 Form 112S (212)

4 Form 112S (212) Page 4 Schedule K Shareholders' Pro Rata Share Items (continued) Total amount 17 a Investment income a Investment expenses c Dividend distriutions paid from accumulated earnings and profits c d Other items and amounts (attach statement) Other Information Reconciliation Schedule L 1 2a a 11 a a EEA 18 Income/loss reconciliation. Comine the amounts on lines 1 through 1 in the far right column. From the result, sutract the sum of the amounts on lines 11 through 12d and 14I Balance Sheets per Books Beginning of tax year End of tax year Assets (a) () (c) (d) Cash Trade notes and accounts receivale... Less allowance for ad dets ( ) ( ) Inventories U.S. government oligations Tax-exempt securities (see instructions).. Other current assets (attach statement).. Loans to shareholders Mortgage and real estate loans Other investments (attach statement)... Buildings and other depreciale assets.. 79,496 9,761 Less accumulated depreciation ( ) ( ) Depletale assets Less accumulated depletion ( ) ( ) Land (net of any amortization) Intangile assets (amortizale only).... Less accumulated amortization ( ) ( ) Other assets (attach statement) Total assets Liailities and Shareholders' Equity Accounts payale Mortgages, notes, onds payale in less than 1 year Other current liailities (attach statement) Loans from shareholders Mortgages, notes, onds payale in 1 year or more Other liailities (attach statement) Capital stock Additional paid-in capital Retained earnings ROBIN CENTER CHIROPRACTIC Adjustments to shareholders' equity (attach statement) ,545 (1,331) (2,94) 1,811 33,524 73,2 6,494 77,536 13,225 15,974 44,655 Statement #22 15,843 Statement #22 22,785 21, Less cost of treasury stock ( ) ( ) Total liailities and shareholders' equity.. 15,974 44,655 Form 112S (212)

5 Schedule M-1 ROBIN CENTER CHIROPRACTIC Reconciliation of Income (Loss) per Books With Income (Loss) per Return Form 112S (212) Page 5 Note. Schedule M-3 required instead of Schedule M-1 if total assets are $1 million or more-see instructions ,715 1 Net income (loss) per ooks 5 Income recorded on ooks this year not included 2 Income included on Schedule K, lines 1, 2, 3c, 4, on Schedule K, lines 1 through 1 (itemize): 5a, 6, 7, 8a, 9, and 1, not recorded on ooks this a Tax-exempt interest $ year (itemize): 3 Expenses recorded on ooks this year not 6 Deductions included on Schedule K, included on Schedule K, lines 1 through 12 and lines 1 through 12 and 14l, not charged 14l (itemize): against ook income this year (itemize): a Depreciation $ a Depreciation $ Travel and entertainment $ 3,83 3, , ,545 7 Add lines 5 and 6 4 Add lines 1 through Income (loss) (Schedule K, line 18). Line 4 less line 7 Schedule M-2 Analysis of Accumulated Adjustments Account, Other Adjustments Account, and Shareholders' Undistriuted Taxale Income Previously Taxed (see instructions) (a) Accumulated () Other adjustments (c) Shareholders' undistriuted adjustments account account taxale income previously taxed ,29 1 Balance at eginning of tax year 2 Ordinary income from page 1, line Other additions.... Statement # ,54 4 Loss from page 1, line ( ) 5 Other reductions.... Statement #3.. ( 5,998 ) ( ) 6 Comine lines 1 through ,878 7 Distriutions other than dividend distriutions. 19,247 8 Balance at end of tax year. Sutract line 7 from line 6. 1,631 EEA Form 112S (212)

6 Schedule K-1 (Form 112S) 212 For calendar year 212, or tax Department of the Treasury Internal Revenue Service year eginning, 212 ending, 2 Shareholder's Share of Income, Deductions, Credits, etc. See page 2 of form and separate instructions. Part I Information Aout the Corporation A Corporation's employer identification numer B Corporation's name, address, city, state, and ZIP code ROBIN CENTER CHIROPRACTIC Part III Shareholder's Share of Current Year Income, Deductions, Credits, and Other Items 1 Ordinary usiness income (loss) 13 Credits a 5 Qualified dividends 14 Foreign transactions Final K-1 Amended K-1 OMB No ,29 Net rental real estate income (loss) 27,54 Other net rental income (loss) Interest income Ordinary dividends 464 LAKELAND AVE NORTH ROBBINSDALE MN Royalties Net short-term capital gain (loss) C IRS Center where corporation filed return E-FILE Part II Information Aout the Shareholder 8a 8 Net long-term capital gain (loss) Collectiles (28%) gain (loss) D E Shareholder's identifying numer Shareholder's name, address, city, state, and ZIP code ALEX CHERNYAVSKY 8c 9 Unrecaptured section 125 gain Net section 1231 gain (loss) 1 Other income (loss) 15 Alternative minimum tax (AMT) items TH ST SE A (1,55) BUFFALO MN F Shareholder's percentage of stock ownership for tax year % 11 Section 179 deduction 16 Items affecting shareholder asis 12 Other deductions 2,168 C 3,83 D 19,247 For IRS Use Only 17 Other information * See attached statement for additional information. For Paperwork Reduction Act Notice, see Instructions for Form 112S. IRS.gov/form112S Schedule K-1 (Form 112S) 212 EEA

7 Schedule K-1 (Form 112S) 212 This list identifies the codes used on Schedule K-1 for all shareholders and provides summarized reporting information for shareholders who file Form 14. For detailed reporting and filing information, see the separate Shareholder's Instructions for Schedule K-1 and the instructions for your income tax return. Code Report on 1. Ordinary usiness income (loss). Determine whether the income (loss) is M Credit for increasing research passive or nonpassive and enter on your return as follows: activities Report on N Credit for employer social Passive loss security and Medicare taxes Passive income Schedule E, line 28, column (g) O Backup withholding Nonpassive loss Schedule E, line 28, column (h) P Other credits Nonpassive income Schedule E, line 28, column (j) 14. Foreign transactions 2. Net rental real estate income (loss) A Name of country or U.S. possession 3. Other net rental income (loss) B Gross income from all sources Form 1116, Part I Net income Schedule E, line 28, column (g) C Gross income sourced at Net loss shareholder level 4. Interest income Form 14, line 8a Foreign gross income sourced at corporate level 5a. Ordinary dividends Form 14, line 9a D Passive category E General category Form 1116, Part I 5. Qualified dividends Form 14, line 9 F Other 6. Royalties Schedule E, line 4 Deductions allocated and apportioned at shareholder level 7. Net short-term capital gain (loss) Schedule D, line 5 G Interest expense Form 1116, Part I H Other Form 1116, Part I 8a. Net long-term capital gain (loss) Schedule D, line 12 Deductions allocated and apportioned at corporate level to foreign source 8. Collectiles (28%) gain (loss) 28% Rate Gain Worksheet, line 4 income (Schedule D instructions) I Passive category 8c. Unrecaptured section 125 gain J General category Form 1116, Part I K Other 9. Net section 1231 gain (loss) Other information 1. Other income (loss) L Total foreign taxes paid Form 1116, Part II Code M Total foreign taxes accrued Form 1116, Part II A Other portfolio income (loss) N Reduction in taxes availale for B Involuntary conversions credit Form 1116, line 12 C Sec contracts & straddles Form 6781, line 1 O Foreign trading gross receipts Form 8873 D Mining exploration costs recapture See Pu. 535 P Extraterritorial income exclusion Form 8873 E Other income (loss) Q Other foreign transactions 15. Alternative minimum tax (AMT) items 11. Section 179 deduction A Post-1986 depreciation adjustment 12. Other deductions See the B Adjusted gain or loss A Cash contriutions (5%) Shareholder's C Depletion (other than oil & gas) B Cash contriutions (3%) Instructions and D Oil, gas, & geothermal - gross income C Noncash contriutions (5%) the Instructions for E Oil, gas, & geothermal - deductions D Noncash contriutions (3%) See the Shareholder's Form 6251 F Other AMT items E Capital gain property to a 5% Instructions organization (3%) 16. Items affecting shareholder asis F Capital gain property (2%) A Tax-exempt interest income Form 14, line 8 G Contriutions (1%) B Other tax-exempt income H Investment interest expense Form 4952, line 1 C Nondeductile expenses I Deductions - royalty income Schedule E, line 19 D Distriutions See the Shareholder's J Section 59(e)(2) expenditures E Repayment of loans from Instructions K Deductions - portfolio (2% floor) Schedule A, line 23 shareholders L Deductions - portfolio (other) Schedule A, line Other information M Preproductive period expenses A Investment income Form 4952, line 4a N Commercial revitalization deduction B Investment expenses Form 4952, line 5 from rental real estate activities See Form 8582 instructions C Qualified rehailitation expenditures O Reforestation expense deduction (other than rental real estate) P Domestic production activities D Basis of energy property information See Form 893 instructions E Recapture of low-income housing Q Qualified production activities income Form 893, line 7 credit (section 42(j)(5)) Form 8611, line 8 R Employer's Form W-2 wages Form 893, line 17 F Recapture of low-income housing S Other deductions credit (other) Form 8611, line 8 G Recapture of investment credit See Form Credits H Recapture of other credits A Low-income housing credit (section I Look-ack interest - completed 42(j)(5)) from pre-28 uildings long-term contracts See Form 8697 B Low-income housing credit (other) from J Look-ack interest - income forecast pre-28 uildings method See Form 8866 C Low-income housing credit (section K Dispositions of property with See the Shareholder's 42(j)(5)) from post-27 uildings section 179 deductions Instructions D Low-income housing credit (other) L Recapture of section 179 from post-27 uildings deduction E Qualified rehailitation expenditures M Section 453(I)(3) information (rental real estate) N Section 453A(c) information F Other rental real estate credits O Section 126() information G Other rental credits P Interest allocale to production See the Shareholder's H Undistriuted capital gains credit Form 14, line 71, ox a expenditures Instructions I Alcohol and cellulosic iofuel fuels Q CCF nonqualified withdrawals credit R Depletion information - oil and gas J Work opportunity credit See the Shareholder's S Amortization of reforestation K Disaled access credit Instructions costs L Empowerment zone and renewal T Section 18(i) information community employment credit U Other information Page 2 EEA N

8 8825 K-1 Rental Real Estate Activity 212 Shareholder/Partner Name Description Type Ownership percentage ALEX CHERNYAVSKY LAKELAND AVE N ROBBINSDALE MN COMMERCIAL 27,54 EIN/SSN Line 17 Line 19 Line 2a Line 21 Income/Loss 4797 Pass-thru Net Totals ,54 27,54 K1_8825~.LD

9 Form 4562 Department of the Treasury Internal Revenue Service (99) Name(s) shown on return Depreciation and Amortization (Including Information on Listed Property) 212 ROBIN CENTER CHIROPRACTIC FORM 112S Part I Election To Expense Certain Property Under Section 179 Part IV See separate instructions. Attach to your tax return. Business or activity to which this form relates 1 Maximum amount (see instructions) 1 2 Total cost of section 179 property placed in service (see instructions) Threshold cost of section 179 property efore reduction in limitation (see instructions) Reduction in limitation. Sutract line 3 from line 2. If zero or less, enter Dollar limitation for tax year. Sutract line 4 from line 1. If zero or less, enter --. If married filing separately, see instructions (a) Description of property () Cost (usiness use only) (c) Elected cost 7 Listed property. Enter the amount from line Total elected cost of section 179 property. Add amounts in column (c), lines 6 and Tentative deduction. Enter the smaller of line 5 or line Carryover of disallowed deduction from line 13 of your 211 Form Business income limitation. Enter the smaller of usiness income (not less than zero) or line 5 (see instructions) Section 179 expense deduction. Add lines 9 and 1, ut do not enter more than line Carryover of disallowed deduction to 213. Add lines 9 and 1, less line Note: Do not use Part II or Part III elow for listed property. Instead, use Part V. Part II Special Depreciation Allowance and Other Depreciation (Do not include listed property.) (See instructions.) 14 Special depreciation allowance for qualified property (other than listed property) placed in service during the tax year (see instructions) Property suject to section 168(f)(1) election Other depreciation (including ACRS) Part III MACRS Depreciation (Do not include listed property.) (See instructions.) Section A 17 MACRS deductions for assets placed in service in tax years eginning efore If you are electing to group any assets placed in service during the tax year into one or more general asset accounts, check here a c d e f g h i 2a c Note: If you have any listed property, complete Part V efore you complete Part I. Section B - Assets Placed in Service During 212 Tax Year Using the General Depreciation System 3-year property 5-year property 7-year property 1-year property 15-year property 2-year property 25-year property 25 yrs. S/L Residential rental 27.5 yrs. MM S/L property 27.5 yrs. MM S/L Nonresidential real 39 yrs. MM S/L property MM S/L Section C - Assets Placed in Service During 212 Tax Year Using the Alternative Depreciation System Class life S/L 12-year 12 yrs. S/L 4-year 4 yrs. MM S/L Summary (See instructions.) 21 Listed property. Enter amount from line Total. Add amounts from line 12, lines 14 through 17, lines 19 and 2 in column (g), and line 21. Enter here and on the appropriate lines of your return. Partnerships and S corporations - see instructions For assets shown aove and placed in service during the current year, enter the portion of the asis attriutale to section 263A costs For Paperwork Reduction Act Notice, see separate instructions. EEA COMPUTER MASSAGE CHAIRS 1, ,299 OMB No Attachment Sequence No. Identifying numer () Month and year (c) Basis for depreciation (d) Recovery (a) Classification of property placed in (usiness/investment use (e) Convention (f) Method (g) Depreciation deduction service only-see instructions) period , 24,265 2,, 5, 2,168 2, ,713 2,168 11,49 3,765 11,48 5 MQ 2 DB ,366 Form 4562 (212)

10 Part V Part VI ROBIN CENTER CHIROPRACTIC Listed Property (Include automoiles, certain other vehicles, certain computers, and property used for Form 4562 (212) Page 2 24a Do you have evidence to support the usiness/investment use claimed? Yes No 24 If "Yes," is the evidence written? Yes No entertainment, recreation, or amusement.) Note: For any vehicle for which you are using the standard mileage rate or deducting lease expense, complete only 24a, 24, columns (a) through (c) of Section A, all of Section B, and Section C if applicale. Section A - Depreciation and Other Information (Caution: See the instructions for limits for passenger automoiles.) (c) (e) (i) (a) () (d) (f) (g) (h) Business/ Basis for depreciation Type of property (list Date placed Cost or other asis Recovery Method/ Depreciation Elected section 179 investment use (usiness/investment vehicles first) in service period Convention deduction cost percentage use only) Special depreciation allowance for qualified listed property placed in service during the tax year and used more than 5% in a qualified usiness use (see instructions) Property used more than 5% in a qualified usiness use: % % % Property used 5% or less in a qualified usiness use: % S/L- % S/L- % S/L- VAN , 13, 28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page Add amounts in column (i), line 26. Enter here and on line 7, page Section B - Information on Use of Vehicles Complete this section for vehicles used y a sole proprietor, partner, or other "more than 5% owner," or related person. If you provided vehicles to your employees, first answer the questions in Section C to see if you meet an exception to completing this section for those vehicles. 3 Total usiness/investment miles driven during the year (do not include commuting miles) 31 Total commuting miles driven during the year 32 Total other personal (noncommuting) miles driven 33 Total miles driven during the year. Add lines 3 through Was the vehicle availale for personal Yes No Yes No Yes No Yes No Yes No Yes No use during off-duty hours? Was the vehicle used primarily y a more than 5% owner or related person? Is another vehicle availale for personal use? Section C - Questions for Employers Who Provide Vehicles for Use y Their Employees Answer these questions to determine if you meet an exception to completing Section B for vehicles used y employees who are not more than 5% owners or related persons (see instructions). 37 Do you maintain a written policy statement that prohiits all personal use of vehicles, including commuting, y Yes No your employees? Do you maintain a written policy statement that prohiits personal use of vehicles, except commuting, y your employees? See the instructions for vehicles used y corporate officers, directors, or 1% or more owners Do you treat all use of vehicles y employees as personal use? Do you provide more than five vehicles to your employees, otain information from your employees aout the use of the vehicles, and retain the information received? Do you meet the requirements concerning qualified automoile demonstration use? (See instructions.) Note: If your answer to 37, 38, 39, 4, or 41 is "Yes," do not complete Section B for the covered vehicles. Amortization (a) () (c) (d) (e) (f) Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle () (c) (d) (e) (f) (a) Amortization Date amortization Amortizale amount Code section Amortization for this year Description of costs period or egins percentage Amortization of costs that egins during your 212 tax year (see instructions): 43 Amortization of costs that egan efore your 212 tax year Total. Add amounts in column (f). See the instructions for where to report 44 EEA Form 4562 (212)

11 Form Part I 4797 Sales of Business Property (Also Involuntary Conversions and Recapture Amounts Under Sections 179 and 28F()(2)) 212 Department of the Treasury Attach to your tax return. Attachment Internal Revenue Service (99) Information aout Form 4797 and its separate instructions is at Sequence No. Name(s) shown on return 1 Enter the gross proceeds from sales or exchanges reported to you for 212 on Form(s) 199-B or 199-S (or sustitute statement) that you are including on line 2, 1, or 2 (see instructions) Identifying numer ROBIN CENTER CHIROPRACTIC Sales or Exchanges of Property Used in a Trade or Business and Involuntary Conversions From Other Than Casualty or Theft - Most Property Held More Than 1 Year (see instructions) (e) Depreciation (f) Cost or other 2 (a) Description () Date acquired (c) Date sold (d) Gross allowed or asis, plus (g) Gain or (loss) of property sales price allowale since improvements and Sutract (f) from the (yr., mo., day) (yr., mo., day) acquisition expense of sale sum of (d) and (e) VAN , 13, 1 OMB No Gain, if any, from Form 4684, line Section 1231 gain from installment sales from Form 6252, line 26 or Section 1231 gain or (loss) from like-kind exchanges from Form Gain, if any, from line 32, from other than casualty or theft Comine lines 2 through 6. Enter the gain or (loss) here and on the appropriate line as follows: Partnerships (except electing large partnerships) and S corporations. Report the gain or (loss) following the instructions for Form 165, Schedule K, line 1, or Form 112S, Schedule K, line 9. Skip lines 8, 9, 11, and 12 elow. 8 Nonrecaptured net section 1231 losses from prior years (see instructions) 8 9 Sutract line 8 from line 7. If zero or less, enter --. If line 9 is zero, enter the gain from line 7 on line 12 elow. If line 9 is more than zero, enter the amount from line 8 on line 12 elow and enter the gain from line 9 as a long-term capital gain on the Schedule D filed with your return (see instructions) Part II 1 Individuals, partners, S corporation shareholders, and all others. If line 7 is zero or a loss, enter the amount from line 7 on line 11 elow and skip lines 8 and 9. If line 7 is a gain and you did not have any prior year section 1231 losses, or they were recaptured in an earlier year, enter the gain from line 7 as a long-term capital gain on the Schedule D filed with your return and skip lines 8, 9, 11, and 12 elow. Ordinary Gains and Losses (see instructions) Ordinary gains and losses not included on lines 11 through 16 (include property held 1 year or less): Loss, if any, from line 7 11 ( ) 12 Gain, if any, from line 7 or amount from line 8, if applicale Gain, if any, from line Net gain or (loss) from Form 4684, lines 31 and 38a Ordinary gain from installment sales from Form 6252, line 25 or Ordinary gain or (loss) from like-kind exchanges from Form Comine lines 1 through For all except individual returns, enter the amount from line 17 on the appropriate line of your return and skip lines a and elow. For individual returns, complete lines a and elow: a If the loss on line 11 includes a loss from Form 4684, line 35, column ()(ii), enter that part of the loss here. Enter the part of the loss from income-producing property on Schedule A (Form 14), line 28, and the part of the loss from property used as an employee on Schedule A (Form 14), line 23. Identify as from "Form 4797, line 18a." See instructions... 18a Redetermine the gain or (loss) on line 17 excluding the loss, if any, on line 18a. Enter here and on Form 14, line For Paperwork Reduction Act Notice, see separate instructions. Form 4797 (212) EEA

12 Form 1 A B C 8825 Rental Real Estate Income and Expenses of a Partnership or an S Corporation (Rev. Decemer 21) Department of the Treasury Internal Revenue Service Name See instructions. Attach to Form 165, Form 165-B, or Form 112S. Show the type and address of each property. For each rental real estate property listed, report the numer of days rented at fair rental value and days with personal use. See instructions. See page 2 to list additional properties. Physical address of each property - street, city, Type - Enter code 1-8; Fair Rental Days state, ZIP code see page 2 for list OMB No Employer identification numer ROBIN CENTER CHIROPRACTIC LAKELAND AVE N ROBBINSDALE MN COMMERCIAL 365 Personal Use Days D Rental Real Estate Income Gross rents 2 Properties A B C D 27,54 Rental Real Estate Expenses Advertising 3 4 Auto and travel 4 5 Cleaning and maintenance 5 6 Commissions 6 7 Insurance 7 8 Legal and other professional fees 8 9 Interest 9 1 Repairs 1 11 Taxes Utilities Wages and salaries Depreciation (see instructions) Other (list) Total expenses for each property. Add lines 3 through Income or (Loss) from each property. Sutract line 16 from line a Total gross rents. Add gross rents from line 2, columns A through H 18a Total expenses. Add total expenses from line 16, columns A through H 19 Net gain (loss) from Form 4797, Part II, line 17, from the disposition of property from rental real estate activities 2 a Net income (loss) from rental real estate activities from partnerships, estates, and trusts in which this partnership or S corporation is a partner or eneficiary (from Schedule K-1) Identify elow the partnerships, estates, or trusts from which net income (loss) is shown on line 2a. Attach a schedule if more space is needed: 27, a 27,54 ( ) (1) Name (2) Employer identification numer 21 Net rental estate income (loss). Comine lines 18a through 2a. Enter the result here and on: 21 Form 165 or 112S: Schedule K, line 2, or Form 165-B: Part I, line 4 For Paperwork Reduction Act Notice, see instructions. EEA 27,54 Form 8825 (12-21)

13 Taxes and Licenses Attachment Note: This information does not transmit to the IRS with e-filed returns. Including with a paper filed return is optional. S CORPORATION NAME EIN 212 ROBIN CENTER CHIROPRACTIC Taxes and Licenses Form 112S Page 1, Line 12 1 State income taxes 1 2 State franchise taxes 2 3 City income taxes 3 4 City franchise taxes 4 5 Local property taxes 5 6 Intangile property taxes 6 7 Payroll taxes 7 8 Less: credit from Form Foreign taxes paid 9 1 Occupancy taxes 1 11 Other miscellaneous taxes Built in gains tax allocated to ordinary income Licenses Total to Form 112S, Page 1, Line ,848 8,97 19,818 ATT_STL.LD

14 Federal Supporting Statements 212 PG1 Name(s) as shown on return FEIN ROBIN CENTER CHIROPRACTIC FORM 112S LINE 19 Statement #2 DESCRIPTION AMOUNT ACCOUNTING 7,58 AUTOMOBILE AND TRUCK EXPENSE 6,532 BANK CHARGES 1,792 DUES AND SUBSCRIPTIONS 373 EDUCATION AND TRAINING 1,541 EQUIPMENT RENTAL/LEASE 16,828 INSURANCE 6,148 5% MEALS AND ENTERTAINMENT 3,831 OFFICE EXPENSE 9,245 OUTSIDE SERVICES/SUB CONTRACTORS 29,928 POSTAGE/SHIPPING 1,175 SUPPLIES 11,554 TELEPHONE 6,417 TRAVEL 968 UNIFORMS 2,89 UTILITIES 7,428 BILLING SERVICE 5,83 CREDIT CARD FEES 291 STORAGE EXPENSE 71 TOTAL 165,242 FORM 112S, SCHEDULE L, LINE 18 OTHER CURRENT LIABILITIES PG1 STM22 DESCRIPTION BEG OF YEAR END OF YEAR US BANK CC ,834 14,434 AMEX CC 718 1,93 6,84 FEDERAL PAYROLL TAX 2,152 1,58 STATE PAYROLL TAX MN CARE TAX TOTAL 15,843 22,785 STATMENT.LD

15 Federal Supporting Statements 212 PG1 Name(s) as shown on return FEIN ROBIN CENTER CHIROPRACTIC SCHEDULE M-2 LINE 3 Statement #29 DESCRIPTION AMOUNT NET RENTAL REAL ESTATE INCOME 27,54 TOTAL 27,54 SCHEDULE M-2 LINE 5 PG1 Statement #3 DESCRIPTION AMOUNT ALLOWED SECTION 179 EXPENSE 2,168 NONDEDUCTIBLE EXPENSES 3,83 TOTAL 5,998 STATMENT.LD

16 MINNESOTA REVENUE S Corporation Return 212 Print or Type Tax year eginning, 212, ending Name of corporation Federal ID numer Minnesota tax ID Current street address 1 2 Minimum fee from M8A, line 21 (see M8A instructions, pg. 9) 2 3 Round amounts to nearest whole dollar 4 Minnesota income tax withheld for nonresident shareholders. If you received Form AWC from a shareholder, check ox:. 4 (enclose Forms AWC) Tax 5 Add lines 1 through and 6 Employer Transit Pass Credit not passed through to shareholders, Credits limited to the sum of lines 1 and 2 aove (enclose Schedule ETP) Sutract line 6 from line Minnesota Nongame Wildlife Fund donation (see instructions, pg. 4). This will reduce your refund or increase your tax Add lines 7 and Enterprise Zone Credit not passed through to shareholders (enclose Schedule EPC) Jo Opportunity Building Zone Jos Credit not passed through to shareholders (enclose Schedule JOBZ) Credit for tuerculosis testing on cattle (see instructions, pg. 5) Estimated tax and/or extension payments made for Add lines 1 through Tax due. If line 9 is more than line 14, sutract line 14 from line Penalty (see instructions, pg. 5) Interest (see instructions, pg. 5) Additional charge for underpayment of estimated tax (attach Schedule EST) AMOUNT DUE. If you entered an amount on line 15, add lines 15 through 18. Refund or Payment method: Electronic (see inst., pg. 2), or Check (attach Form PV4) 19 X Amount 2 Overpayment. If line 14 is more than the sum of lines Due 9 and 18, sutract line 9 and line 18 from line Amount of line 2 to e credited to your 213 estimated tax REFUND. Sutract line 21 from line M8 Check if new address Former name, if changed since 211 return: City State Zip code Numer of enclosed Numer of Schedules KS: shareholders: Place an X in all that apply: ROBIN CENTER CHIROPRACTIC LAKELAND AVE NORTH ROBBINSDALE MN Initial Composite Financial Qualified Suchapter Qualified usiness partici- Out of usiness (see return income tax institution S Susidiary pating in a JOBZ zone instructions, pg. 4) S corporation taxes (place an X in all that apply): federal Schedule D taxes passive income LIFO recapture Composite income tax for nonresident shareholders (enclose computation) (enclose M8A) (enclose Schedules KS) 23 To have your refund direct deposited, enter the following. Otherwise, you will receive a check. Account type: Routing numer Account numer (use an account not assoc. with any foreign anks) Checking Savings Signatures Signature of officer Date Daytime phone I authorize the MN Dept. of X Revenue to discuss this tax return with the person elow. Print name of officer address for correspondence, if desired This address elongs to: Employee Paid preparer Other ALEX CHERNYAVSKY Paid preparer's signature Date Daytime phone Preparer's PTIN Include a complete copy of federal Form 112S, Schedules K and K-1, and other federal schedules Mail to: Minnesota S Corporation Income Tax, Mail Station 177, St. Paul, MN P ID 1121

17 MINNESOTA REVENUE Apportionment and Minimum Fee 212 X Place an X in the ox if you conduct all activity in Minnesota, and enter 1. on line 18. If you're a qualified usiness participating in a JOBZ zone in Minnesota and all your property and payroll are within the zone, you are exempt from the minimum fee. Enter zero on line 21 elow and on line 2 of Form M8. Property Ratio Payroll Ratio Sales Ratio Apportionment/ Minimum Fee 1 Average inventory 1 2 Average tangile property (at original cost) Average land owned/used (at original cost) Capitalized rents (gross rents x 8) 5 6 Total property (add lines 1-5; if Col. A is zero, see inst., pg. 7) 6 7 Minnesota property factor (divide each line 6B amount y line 6A; carry to five decimal places) 4 A ID M8A B B B 8 Property factor weight Weighted ratio for PROPERTY (multiply line 7 y line 8) 9 1 Payroll/officer's compensation (if Col. A is zero, see inst., pg. 7) 1 11 Minnesota payroll factor (divide each line 1B amount y line 1A; carry to five decimal places) Payroll factor weight Weighted ratio for PAYROLL (multiply line 11 y line 12) Sales or receipts (if a financial institution or if Col. A is zero, see inst., pg. 7) Minnesota sales factor (divide each line 14B amount y line 14A; carry to five decimal places) Sales factor weight Weighted ratio for SALES (multiply line 15 y line 16) 18 APPORTIONMENT FACTOR (Add lines 9, 13 and 17 in each column OR if you conduct all activity in Minnesota, enter 1. on line 18) Minimum fee calculation (read instructions, pg. 9) 19 Adjustments (see instructions, pg. 9) 2 21 Financial institutions only: average intangile property (see inst., pg. 8) Add lines 6, 1, 14 and Minimum fee (see tale elow) Add line 21 amounts and enter on Form M8, line 2. S corporation name If the amount Enter this amount If the amount Enter this amount on line 2 is: on line 21: on line 2 is: on line 21: FEIN Minnesota tax ID less than $5, $ $5,, to $9,999,999 $1, $5, to $999,999 $1 $1,, to $19,999,999 $2, $1,, to $4,999,999 $3 $2,, or more $5, QSSS designated filer Total In and Outside Minnesota In Minnesota In Minnesota In Minnesota ROBIN CENT

18 ROBIN CENTER CHIROPRACTIC MINNESOTA REVENUE Shareholder's Share of Income, Credits and Modifications 212 MNKS_SUM 1121 Calculate lines 1-17 the same for all resident and nonresident shareholders. Calculate lines for nonresident shareholders only. Round amounts to the nearest whole dollar. Modifications to Federal Taxale Income 1 Interest income from non-minnesota state and municipal onds State income tax deducted in arriving at ordinary or net rental income Expenses deducted that are attriutale to income not taxed y Minnesota (other than interest or mutual fund dividends from U.S. onds) If the S corporation elected section 179 expensing, enter the shareholder's flow-through section 179 expensing for Minnesota purposes % of shareholder's pro rata share of federal onus depreciation Federal tax-exempt susidies paid to employers for providing prescription drug coverage for their retirees A 7 Fines, fees and penalties deducted federally l l as a trade or usiness expense Addition due to federal changes not adopted y Minnesota s h 9 Interest from U.S. government ond oligations, minus any expenses a r deducted on the federal return that are attriutale to this income e 1 JOBZ usiness and investment income exemptions h o 11 Sutraction due to federal changes not adopted y Minnesota l d 12 Employer transit pass credit e 13 Enterprise zone credit r s 14 Credit for increasing research activities Credit for historic structure rehailitation & NPS project numer: Jos credit for participating in a JOBZ zone Relating to Alternative Minimum Tax 17 Intangile drilling costs Gross income from oil, gas and geothermal properties Deductions allocale to oil, gas and geothermal properties Depletion Minnesota Portion of Amounts From Federal Schedule K-1 (112S) 21 Minnesota source gross income Ordinary Minnesota source income (loss) N from trade or usiness activities o 23 Income (loss) from Minnesota rental real estate n r and other Minnesota rental activities e 24 Interest income s i 25 Ordinary dividends d 26 Royalties e n 27 Net Minnesota short-term capital gain (loss) t 28 Net Minnesota long-term capital gain (loss) Section 1231 Minnesota net gain (loss) s h 3 Other Minnesota income (loss). (Descrie type of income a or include separate sheet: ) 3 r e 31 Section 179 expense deduction apportionale to Minnesota ( ) h 32 S Corporation's MN apportionment factor (line 18 of M8A) o l Composite Income Tax or Nonresident Withholding d 33 Minnesota source distriutive income e 34 Minnesota composite income tax paid y S corporation. If the r s shareholder elected composite income tax Minnesota income tax withheld for nonresident shareholder not electing to file composite income tax. If the shareholder completed and signed a Form AWC