C Corporation Tax Return 2012

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CD-405 (SD) For calendar year 2012, or other tax year beginning C Corporation Tax Return 2012 North Carolina Department of Revenue 12 45 12 and ending 12 45 78 DOR Use Only BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOP BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHI BCDEFGHIJKLMNOPQRST B 12345 Fed Schedule M-3 is attached Has Escheatable Property Initial Filer Final Return Captive REIT NC-478 Federal Employer ID Number N.C. Secretary of State ID Number 1234567 NICS Code 123456 CD-479 Nonprofit/Tax Exempt mended Return Combined Return Non U.S./Foreign Is this corporation related to another corporation as: Parent Subsidiary ffiliate BCD BCD 12345 1234567 123456 M3 EP IF FR PP 12345678 PFSP F RE 478 479 NP/TE TN PR SUB FF R CR NF BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQR BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHI BCDEFGHIJKLMNOPQRST B 12345 BD 08 20-29E GR 123 09 21 31 T 123 10-22 32 01 11-24 36 123456 HCE 13 26 EU 02 15-27 12 37 03 16-29 37B 05 17 1234567 29B 40 06 18-29C 41 07 19-29D 42 Sch. Computation of Franchise Tax 1. Capital Stock, Surplus, & Undivided Profits Holding Company Exception Investment in N.C. Tangible Property 3. ppraised Value of N.C. Tangible Property 4. Taxable mount Total Franchise Tax Due 6. pplication for Franchise Tax Extension 7. Tax Credits 8. Franchise Tax Due Sign Return Below Refund Due 9. Franchise Tax Overpaid Sch. B Computation of Corporate Income Tax Y 10. Federal Taxable Income - 11. djustments to Federal Taxable Income - 1 Net Income Before Contributions - 13. Contributions to Donees Outside N.C. 14. N.C. Taxable Income - 1 Nonapportionable Income - 16. pportionable Income - 17. pportionment Factor Payment Due Signature and Title of Officer Corporate Telephone Number Date Signature of Paid Preparer Preparer s Telephone Number Preparer s FEIN, SSN, or PTIN I certify that, to the best of my knowledge, this return is accurate and complete. FEIN SSN PTIN Mail to: NCDOR, P.O. Box 25000, Raleigh, N.C. 27640-0500. Returns are due by the 15th day of the 4th month after the end of the income year.

CD-405 2012 Page 2 (SD) Legal Name (First 10 Characters) BCDEFGHIJ Federal Employer ID Number CD-405 Line-by-Line Information Enter the amount of bonus depreciation from Schedule H, Line 1(g) Sch. B Computation of Corporate Income Tax Sch. D Investment in N.C. Tangible Property 18. Income pportioned to N.C. - Inventory valuation method BCD 19. Nonapportionable Income llocated to N.C. - 1. Total inventories located in N.C. 20. Income Subject to N.C. Tax - Total furniture, fixtures, and M & E located in N.C. 21. % Depletion over Cost - N.C. Property 3. Total land and buildings located in N.C. 2 Net Economic Loss (ttach schedule) 4. Total leasehold improvements and 23. Income Before Contributions to N.C. Donees - 24. 2 26. 27. 28. Contributions to N.C. Donees Net Taxable Income - N.C. Net Income Tax nnual Report Fee 12 dd Lines 26 and 27 29. Payments and Credits a. pplication for Income Tax Extension b. 2012 Estimated Tax (previous payments if amended) c. Partnership (include Form D-403, NC K-1) d. Nonresident Withholding (include 1099 or W-2) 30. dd Lines 29a through 29e 31. Income Tax Due 3 Income Tax Overpaid Sch. C e. Tax Credits Tax Due or Refund 33. Franchise Tax Due or Overpayment 34. Income Tax Due or Overpayment 3 Balance of Tax Due or Overpayment - 36. Underpayment of Estimated Income Tax EU. Exception to Underpayment of Estimated Tax 37. a. Interest b. Penalties 38. Total Due 39. Overpayment 40. 2013 Estimated Income Tax 41. N.C. Nongame and Endangered Wildlife Fund 4 mount to be Refunded Capital Stock, Surplus, and Undivided Profits - - 123456 1. Total capital stock outstanding less cost of treasury stock Paid-in or capital surplus 3. Retained earnings 4. Other surplus Deferred or unearned income 6. llowance for bad debts 7. LIFO reserves 8. Other reserves that do not represent definite and accrued legal liabilities (ttach schedule) 9. dd Lines 1 through 8 10. ffiliated indebtedness (ttach schedule) BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFG 11. Line 9 plus (or minus) Line 10 1 pportionment factor 13. Capital Stock, Surplus, and Undivided Profits other N.C. tangible property dd Lines 1 through 4 6. cc. depreciation, depletion, and amortization with respect to N.C. tangible property 7. Debts existing for N.C. real estate ppraised value of N.C. tangible property 8. Investment in N.C. Tangible Property Sch. E ppraised Value of N.C. Tangible Property 1. County tax value of N.C. tangible property Sch. G Federal Taxable Income Before NOL Deduction 1. a. Merchant card and third-party payments b. Gross receipts or sales 123 c. Returns and allowances d. Balance - Line 1a plus 1b minus Line 1c Cost of goods sold (ttach schedule) 3. Gross Profit (Line 1d minus Line 2) 4. Dividends (ttach schedule) a. Interest on obligations of U.S. and its instrumentalities b. Other interest 6. Gross rents 7. Gross royalties 8. Capital gain net income (ttach schedule) 9. Net gain (loss) (ttach schedule) 10. Other income (ttach schedule) 11. Total Income 1 Compensation of officers (ttach schedule) 13. Salaries and wages (less employment credits) 14. Repairs and maintenance 1 Bad debts 16. Rents 17. Taxes and licenses 18. Interest 19. Charitable contributions 20. a. Depreciation BCDEFGHIJKLMNOPQRSTUV b. Depreciation included in cost of goods sold BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFG c. Balance - Line 20a minus 20b 21. Depletion 2 dvertising 23. Pension, profit-sharing, and similar plans 24. Employee benefit programs 2 Domestic production activities deduction 26. Other deductions (ttach schedule) 27. Total Deductions 28. Taxable Income Per Federal Return Before NOL and Special Deductions 29. Special Deductions 30. Federal Taxable Income

CD-405 2012 Page 3 (SD) Sch. H 3. BCDEFGHIJ Legal Name (First 10 Characters) Federal Employer ID Number 1. dditions 4. djustments to Federal Taxable Income Deductions a. U.S. obligation interest (net of expenses) b. Other deductible dividends c. Dividends received from captive REITs d. Royalties received from related members a. Taxes based on net income b. Dividends paid by captive REITs c. Contributions d. Royalties paid to related members e. Expenses attributable to income not taxed 1a. 1b. 1c. 1d. 1e. f. Domestic production activities deduction 1f. g. Bonus depreciation 1g. h. Other (ttach schedule) 1h. Total dditions e. Interest on deposits with FHLB (net of expenses) S&L s only 3e. f. Bonus depreciation 3f. g. Section 179 expense deduction 3g. h. Other (ttach schedule) 3h. Total Deductions 4. djustments to Federal Taxable Income 3a. 3b. 3c. 3d. Sch. I Contributions 1. Contributions to Donees Outside N.C. a. Total contributions to donees outside N.C. b. Multiply Schedule B, Line 12 by 5% c. mount Deductible Contributions to N.C. Donees a. Total contributions to N.C. donees other than those listed in Line 2d b. Multiply Sch. B, Line 23 by 5% c. Enter the lesser of Line 2a or 2b d. Total contributions to the State of N.C. and its political subdivisions e. mount Deductible 1a. 1b. 1c. 2a. 2b. 2c. 2d. 2e. Other Information - ll Taxpayers Must Complete this Schedule 1. a. State of incorporation BCDEFGHIJKL b. Date incorporated 12 45 78 Date of N.C. Certificate of uthority 12 45 78 3. a. Regular or principal trade or business in N.C. BCDEFGHIJKL b. Regular or principal trade or business everywhere BCDEFGHIJKL BCDEFGHIJKL 4. Principal place business is directed or managed What was the last year the IRS redetermined the corporation s federal taxable income? 6. a. Were adjustments reported to N.C.? 7. 1234 b. If so, when? 12 45 78 Does this corporation finance or discount its receivables through a related or an affiliated company? 8. Is this corporation subject to franchise tax but not N.C. income tax because the corporation s income tax activities are protected under P.L. 86-272? (If yes, attach explanation) 9. Officers names and addresses: President Vice-President Secretary Treasurer BCDEFGHIJKLMNOPQRSTUVWXYZB BCDEFGHIJKLMNOPQRSTUVWXYZB BCDEFGHIJKLMNOPQRSTUVWXYZB BCDEFGHIJKLMNOPQRSTUVWXYZB BCDEFGHIJKLMNOPQRSTUVWXYZB BCDEFGHIJKLMNOPQRSTUVWXYZB BCDEFGHIJKLMNOPQRSTUVWXYZB BCDEFGHIJKLMNOPQRSTUVWXYZB Explanation of Changes for mended Return: BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZ BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZ BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZ BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZ

CD-405 2012 Page 4 (SD) Sch. L 1. 3. 4. 6. 7. 8. 9. 10. 11. 1 13. 14. 1 16. 17. 18. 19. 20. 21. 2 23. 24. 2 26. 27. 28. BCDEFGHIJ Legal Name (First 10 Characters) Federal Employer ID Number Cash Balance Sheet per Books ssets a. Trade notes and accounts receivable b. Less allowance for bad debts Inventories a. U.S. government obligations b. State and other obligations Tax-exempt securities Other current assets (ttach schedule) Loans to shareholders Mortgage and real estate loans Other investments (ttach schedule) a. Buildings and other depreciable assets b. Less accumulated depreciation a. Depletable assets b. Less accumulated depletion Land (net of any amortization) a. Intangible assets (amortizable only) b. Less accumulated amortization Other assets (ttach schedule) Total ssets Liabilities and Shareholders Equity ccounts payable Mortgages, notes, and bonds payable in less than 1 year Other current liabilities (ttach schedule) Loans from shareholders Mortgages, notes, and bonds payable in 1 year or more Other liabilities (ttach schedule) Capital stock: a. Preferred Stock b. Common Stock dditional paid-in capital Retained earnings ppropriated (ttach schedule) Retained earnings Unappropriated djustments to shareholders equity (ttach schedule) Less cost of treasury stock Total Liabilities and Shareholders Equity 6. dd Lines 1 through 5 (a) 12 (12) 12 (12) 12 (12) 12 (12) 12 12 Beginning of Tax Year 9. 10. (b) 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 123 12 12 12 12 12 12 12 12 12 12 12 (12) 12 dd Lines 7 and 8 Income (c) 12 (12) 12 (12) 12 (12) 12 (12) 12 12 Sch. M-1 Reconciliation of Income (Loss) per Books with Income per Return 1. Net income (loss) per books 7. Income recorded on books this year not Federal income tax included on this return: 3. Excess of capital losses over capital gains Tax-exempt interest $ 12345678 4. Income subject to tax not recorded on books this year: BCDEFGHIJKLMNOPQRSTU BCDEFGHIJKLMNOPQRSTU BCDEFGHIJKLMNOPQRSTU Expenses recorded on books this year 8. Deductions on this return not charged not deducted on this return: against book income this year: a. Depreciation $ 12345678 a. Depreciation $ 12345678 b. Charitable Contributions $ 12345678 b. Charitable Contributions $ 12345678 c. Travel and entertainment $ 12345678 BCDEFGHIJKLMNOPQRSTU BCDEFGHIJKLMNOPQRSTU BCDEFGHIJKLMNOPQRSTU BCDEFGHIJKLMNOPQRSTU End of Tax Year (d) 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 123 12 12 12 12 12 12 12 12 12 12 12 (12) 12 This page must be filed with this form.

CD-405 2012 Page 5 (SD) BCDEFGHIJ Legal Name (First 10 Characters) Federal Employer ID Number Sch M-2 Retained Earnings nalysis 1. Balance at beginning of year Net income (loss) per books 3. Other increases: BCDEFGHIJKLMNOPQR BCDEFGHIJKLMNOPQRSTUVWXY BCDEFGHIJKLMNOPQRSTUVWXY 4. dd Lines 1, 2, and 3 6. 7. 8. Distributions: Other decreases: dd Lines 5 and 6 a. Cash b. Stock Balance at End of Year c. Property BCDEFGHIJKLMNOP Sch. N Nonapportionable Income Nonapportionable Income Gross mounts Related Expenses Net mounts Net mounts llocated 1. Nonapportionable Income Nonapportionable Income llocated to N.C. Directly to N.C. BCDEFGHIJKLMNOPQRSTUVWXYZBCDEF BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVW BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVW BCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVWXYZBCDEFGHIJKLMNOPQRSTUVW Explanation of why income listed is nonapportionable income rather than apportionable income: Sch. O Part 1. Part 1. Land Buildings 3. Inventories 4. Other property Total 9. Gross Payroll 10. 14. Computation of pportionment Factor 6. verage value of property 7. Rented Property 8. Property Factor Compensation of general executive officers 11. Payroll Factor 1 Sales Factor 13. Sales Factor Domestic and Other Corporations Not pportioning Franchise or Income Outside N.C. Corporations pportioning Franchise or Income to N.C. and to Other States Total of Factors 1. Within North Carolina (a) Beginning Period (b) Ending Period (a) Beginning Period Total Everywhere (b) Ending Period Factor 1 N.C. pportionment Factor Part 3. Corporations pportioning Franchise or Income to N.C. and to Other States Using Single Sales Factor Part 4. Special pportionment

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