Form 990 Return of Organization Exempt From Income Tax OMB No 15450047 Under Section SOt(e), 527, or 4947(a)(7) of the Internal Revenue Code (except black lung benefit trust or private foundation) 2002 Department of the Treasury .en 1o Public Internal Revenue Serve W The organization may have to use a coDV of this return to satisfy stele reportmo requirements A For the 2002 calendar ear, or tax ear beginning B Check If applicable C Name of organization Pluu Address change label or Numbed end Street (or P O box d mail n not EalrvereE to street Name change p, o, address D lnitial return $;; 4720 Randol h Street so.mo Fmaf return inswa City or town State or country ZIP t4 Accounting method tion, L F-1 Amended return Lincoln NE :1 Other (specify) go Application pending & Section 50t(c)(J) organizations and 4B67(a)(7) nonexempt charitable H and I are not applicable to section 527 organizations trusts must attach a completed Schedule A (Form 990 or 990-M M(a) Is role a prouv arum is ertuww? 1:1 Yes 21 No X(E) If 'Yes' enter number of affiliates to, n/a

H(c) Are ell affiliates included? 1:1 Yes ElNo J ORGANIZATION TYPE 3 ) " (insert no ) 1 14847(e)(1) OR 1 577 (11 'No,' attach a list Sea instrucLOns

K Check here " uif the organization's gross receipts ere normally not more than $25,000 The Hid) Is this a separate return filed by an or anizabonE] organization need not file a return with the IRS, but d the organization received a Form 990 Package in the covered by a group ruling? ~ Yea Ho mail, it should file a return without financial data SOME STATES REQUIRE A COMPLETE RETURN

M Check PSW U A the organization is NOT required W attach B (Form 990 880.E2 or B90~PF) Revenue, Expenses, and Changes In Net Assets or Fund Balances (See page 17 of the instructions ) 1 Contributions, grits, grants, and similar amounts received a Direct public support 1a b Indeed public support 1b I c Government contributions (grants) 1c d TOTAL (add lines 1a through 1c) (cash $ 638,143 noncash $ 2 Program service revenue including government fees and contracts (from Part VII, line 93) 3 Membership dues and assessments 4 Interest on sarongs and temporary cash investments 5 Dividends and interest from securities 6 a Gross rents Ba b Less rental expenses 6b c Net rental income or (loss) (subtract line 6b from line 6a) 7 Other investment income (describe B a Gross amount from sales of assets other A Securities B C than inventory 8a aq' b Less cost or other basis and sales expenses 8b k0o? c Gain or (loss) (attach schedule) 0 Bc d Net gain or (loss) (combine line Bc, columns (A) and (B)) 9 Special events and activities (attach schedule) a Gross revenue (not including $ of contributions reported on line 1a) 9a b Less deed expenses other than fundraising expenses 9b c Net income or (loss) from special events (subtract line 9b from line 9a) 10 a Gross sates of inventory, less returns and allowances 10a b Less cast of goods sold tOb T c Gross profit or (loss) from sales of inventory (attach schedule) (subtract line tOb from line 10a) V 11 Other revenue (from Part VII, line 103) 12 TOTAL REVENUE add lines 1d 2 3 4 5 6c 7 Bd 9c 10c and 11 73 Program services (from line 44, column (B)) 14 Management and general (from line 44, column (C)) U m 15 Fundraising (from line 44, column (D)) O 16 Payments to affiliates (attach schedule) °° 17 TOTAL EXPENSES add lines 16 and 44 column A 18 Excess or (defeat) for the year (subtract line 17 from line 12) I UG D EN U. 19 Net assets or fund balances at beginning of year (from line 73, column'(A3)r- 20 Other changes in net assets or fund balances (attach explanation) 21 Net assets or fund balances at end of ear combine lines 18 19 and 20 (rrtn) For Paperwork Reduction Act Notice, see the separate Instructions Form 990 (2002) l Form 990 ,2002 ' Tabitha Inc 47-0377998 Pa ge 2 P81t f~~ ~' Statement of All organizations must complete column (A) Columns (B) (C) and (D) are required for section 501(c)(3) end (4) organizations Functional Expenses end section 4947(a)(1) nonexempt chantable (rusts but optional for others (See page 21 0l the instructions )

Do not include amounts reported on line (B) Program I (C) Management I (A) TOW( I (D) Fundraising 66, 86, 9b, f06, or 16 of Part 1 services and general 22 Grants and allocations (attach schedule) (cash $ noncash $ 23 Specific assistance to individuals (attach schedule) 24 Benefits paid to or for members (attach schedule) 24 25 Compensation of officers, directors, etc 26 Other salaries and wages 27 Pension plan contributions 28 Other employee benefits 29 Payroll taxes 30 Professional fundraising fees 30 31 Accounting fees 32 Legal fees 33 Supplies 34 Telephone 35 Postage and shipping 36 Occupancy 37 Equipment rental and maintenance 38 Punting and publications 39 Travel 40 Conferences, conventions, and meetings 41 Interest 42 Depreciation, depletion, etc (attach schedule) 43 Other expenses not covered above (itemize) a 43a b see statement two 43b c 43c

44 TOTAL FUNCTIONAL EVIENSES (add Inn 22 through 43) ORGANIZATIONS COMPLETING COLUMNS (B){D) CARRY THESE TOTALS TO LINES 7}15

JOINT COSTS Check " U if you are following SOP 98-2 Are any point costs from a combined educational campaign end fundraising solicitation reported in (B) Program services? " a Yas ~X No If 'Yes." enter (I) the aggregate amount of these joint costs S N/A , (it) the amount allocated to Program services

Raok: ~ Statement of Program Service Accompli 24 of the instructions ) Program Service What is the organizations primary exempt purpose? Iii Expenses Required la 501(c)(7) end All organizations must describe their exempt purpose achievements in a clear and concise manner State we number HIaVs anC,19,71aN1) of clients served, publications issued, etc Discuss achievements that are not measurable (Section 501(c)(3) and (4) trusts but Optional far oNl7 ) organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of grants and allophone to others )

Form 990 (2002) Form 990 (2002) Tabitha, Inc 47-0377998 Page 3 aR IV,_. " Balance Sheets (See page 24 of the instructions )

Note Whet required, attached schedules and amounts within the description (A) I I (B) column should be /or end-of-year amounts only Beginning of year ~ End of year 45 Cash - non-interest-bearing 46 Sarongs and temporary cash investments 46

47 a Accounts receivable 47a b Less allowance for doubtful accounts 47b

48 a Pledges receivable 48a 0 b Less allowance for doubtful accounts 48b 0 49 Grants receivable 50 Recervables from officers, directors, trustees, and key employees (attach schedule) 51 a Other notes and loans receivable (attach p schedule) 51a 0 b Less allowance for doubtful accounts 51 b 0 4 52 Inventories for sale or use 53 Prepaid expenses and deferred charges 54 Investments - securities (attach schedule) " ~ Cost ~ FMV 55 a Investments - land, buildings, and equipment basis see stmt 1 55a 18,683,417 b Less accumulated deprecation (attach schedule) see stmt 1 55b 11 ,801 ,778 56 Investments - other (attach schedule) 57 a Land, buildings, and equipment basis 57a 0 b Less accumulated depreciation (attach schedule) 57b 0 58 Other assets (describe " See Stmt 4 )

60 Accounts payable and accrued expenses 61 Grants payable 62 Deferred revenue 63 Loans from officers, directors, trustees, and key employees (attach schedule) 84 a Tax-exempt bond liabilities (attach schedule) see sent 5 b Mortgages end other notes payable (attach schedule) see sent s 65 Other liabilities (describe " see statement 13 )

Organizations that follow SFAS 717, check here W U and complete lines 67 through 69 and lines 73 and 74 0 67 Unrestricted d ~+ 68 Temporarily restricted 69 Permanently restricted Organizations that do not follow SFAS 117, check here t and complete lines 70 through 74 70 Capital stock, trust principal, or current funds 71 Paid-in or capital surplus, or land, building, and equipment fund $ 72 Retained earnings, endowment, accumulated income, or other funds Q 73 TOTAL NET ASSETS OR FUND BALANCES (add lines 67 through 69 OR lines 70 through 72, column (A) MUST equal line 19, column (B) MUST equal line 21) 1 74 TOTAL LIABILITIES AND NET ASSETS / FUND BALANCES (add lines 66 and 73) L 10,388,1631 74 I 1 Form 990 is available for public inspection and, for some people, serves as the primary or sole source of information about a particular organization How the public perceives an organization in such cases may be determined by the information presented on it return Therefore, please make sure the return is complete and accurate and fully describes, in Part III, the organization's programs and accomplishments Reconciliation of Revenue per Audited Reconciliation of Expenses per Audited Financial Statements with Revenue per Financial Statements with Expenses per

a Total revenue, gains, and other support a Total expenses and losses per per audited financial statements " a 24 112 533 audited financial statements b Amounts included on line a but not b Amounts included on line a but not on line 12, Form 990 on line 17, Form 990 (1) Net unrealized gains (7) Donated services on investments $ and use of facilities $ (2) Donated services and (2) Prior year adjustments use of facilities reported on line 20, (3) Recoveries of prior Form 990 E year grants $ (3) Losses reported on (4) Other (specify) line 20, Form 990 $ (4) Other (specify)

Add amounts on lines (1) through (4) " b 0 Add amounts on lines (1) through (4) c Line a minus line b I. c 24 112 533 c Line a minus line b d Amounts included on line 12, d Amounts included on line 17, Forth 990 but not on line a Forth 990 but not on line a (1) Investment expenses (1) Investment expenses not included on line not included on line 6b, Form 990 $ 6b, Forth 990 $ - (2) Other (specify) (2) Other (specify) reclass chancy ~ reclass chanN

Add amounts on lines (1) and (2) 11. Add amounts on lines (1) and (2) 10 e Total revenue per line 12, Form 990 e Total expenses per line 17, Forth 990

List of Officers, Directors, Trustees, and Key Employees (List each one even ff not compensated, see page 26 of the instructions ) (C) Compensation (D) Contnbuhons to (E) Expense (B) Title and average hours per (A) Name and address (IF NOT PAID, employee benefit plans 8 account and other week devoted to position ENTER -0. ) deferred compensation allowances

75 Did any officer, director, trustee, or key employee receive aggregate compensation of more than $100,000 from your o anlzaUOn and all related organizations, of which more than 510,000 was provided by the related organizations? " Yes ~ No If 'Yes,' attach schedule-see page 26 Of the Instructions

Form 990 (2002) 1 Tabitha, Inc 47-0377998 Pace 5 Va rtm V1919 0 (200?1-Other Information (See page 27 of the instructions ) Yes No 76 Did the organization engage in any activity got previously reported to tie IRS7 If 'Yes 'attach a detailed descnplion of each activity 76 X 77 Were any changes made in the organizing or governing documents but not reported to the IRS 77 X If "Yes ;' attach a conformed copy of the changes MM SK 78 a Did the organization have unrelated business gross income of $7,000 or more during the year covered by this return? 78a X b If "Yes," has it filed a tax return on FORM 990-T for this year? We 78b 79 Was there a liquidation, dissolution, termination, or substantial contraction during the year? II "Yes," attach a statement 79 X 80 a Is the organization related (other than by association with a statewide or nationwide organization) through common membership, governing bodies, trustees, officers, etc , to any other exempt or nonexempt organization? 80a X b If "Yes ;" enter the name of the organization " see statement eight and check whether it is U exempt OR nonexempt 81 a Enter direct or endued political expenditures See tine 81 instructions Bta 0 b Did the organization file FORM 1120-POL for this years Na 81b I 82 a Did the organization receive donated services or the use of materials, equipment, or facilities at no charge or at substantially less than fair rental values 82a X b If "Yes," you may indicate the value of these Items here Do not include this amount as revenue in Part I or as an expense in Part II (See instructions m Part III ) 82b donated svcs 83 a Did the organization comply with the public inspection requirements for returns and exemption applications 83a X b Did the organization comply with the disclosure requirements relating to quid pro quo contributions 83b X 84 a Did the organization solicit any contributions or gifts that were not tax deductibles 84a X b If "Yes," did the organization include with every solicitation an express statement that such contnbutions or gifts were not tax deductible? Na 84b 85 501(c)(4), (5), or (6) organizations a Were substantially all dues nondeductible by members nia 85a b Did the organization make only in-house lobbying expenditures of $2,000 or less n/a 85b If "Yes" was answered to either 85a or BSb, DO NOT complete 85c through 85h below unless the organization received a waiver for proxy tax owed for the poor year c Dues, assessments, and similar amounts from members nia 85c d Section 162(e) lobbying and political expenditures Na 85d e Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices Na 85e f Taxable amount of lobbying and political expenditures (line 85d less BSe) Na 85f g Does the organization elect to pay the section 6033(e) tax on the amount on line 85f? nla 85 h If section 6033(e)(1)(A) dues notices were sent, does the organization agree to add the amount on line 85f to its reasonable estimate of dues allocable to nondeductible lobbying and political expenditures for the following tax year? Na BSh 86 501(c)(7) orgs Enter a Initiation fees and capital contributions included on line 12 nl 86a b Gross receipts, included on line 12, for public use of club facilities nii 87 501(c)(12) orgs Enter a Gross income from members or shareholders ni 87a b Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them ) ni 87b 88 At any time during the year, did the organization own a 50% or greater interest in a taxable corporation or partnership, or an entity disregarded as separate from the organization under Regulations sections 301 7701-2 and 301 7701-39 If "Yes;" complete Part IX X 89 a 501(c)(3) organizations Enter Amount of lax imposed on the organization during the year under section 4911 W 0 , section 4912 . 0 , section 4955 11, 0 b 501(c)(3) and 501(c)(4) orgs Did the organization engage in any section 4958 excess benefit transaction during the year or did it become aware of an excess benefit transaction from a poor yeah If "Yes," attach a statement explaining each transaction 89b X e Enter Amount of tax imposed on the organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 ll~ none d Enter Amount of tax on line 89c, above, reimbursed by the organization " none 90 a List the states with which a copy of this return is filed " none b Number of employees employed in the pay period that includes March 12, 2002 (See instructions ) ~ 90b ~ 664 91 The books are in care of W Tabitha Inc Telephone no ll~ 402-483-7671 Located at 10- 4720 Randolph Street Lincoln NE ZIP + 4 t 68510 92 Section 4947(a)(1) nonexempt charitable trusts filing Forth 990 in lieu of FORM 1041 - Check here and enter the amount of lax-exempt interest received or accrued during the tax year 10-1 92 In/a Farm 990 (2002) s of Activities (See F 31 of the instructions ) Note Enter gross amounts unless otherwise Unrelated to. i5 income Excluded by section 572 513 or 574 indicated (B) (C) (D) Related or exempt function income 93 Program service revenue Business code Amount Exclusion code Amount a Elderly Health Care-Child and Adult 7.670.601 b Meals on Wheels e Employee Cafe and Vending d Mamt Services for Affiliates/Others e Maint to tax exempt affiliates f MedicareMlediwid payments p Fees end conVaW from government apanaes 94 Membership dues end assessments 95 Interest on uvsqa W temporary ugh IrtnsYMnlt 98 Dividends and interest from securities 97 Net rental income or (loss) from real estate a debt-financed property b not debt-financed property 98 NCI named income w (011i) fAssn Wrw* Property 99 Other investment income 100 Gin w (loss) norm Was of assets Other than missroory 101 Nat income or (loss) from special events 102 Gross profit or (loss) from sales o1 inventory 703 Other revenue a b e d e 104 Subtotal (add columns (B), (D), and (E)) 105 TOTAL (add line 704, columns (B), (D), and (E)) 111. 23,911,976

of Activities to the of Exempt Purposes (See page 32 of the instructions Line No Explain how each activity for which income Is reported in column (E) of Part VII contributed importantly to the accomplishment lot the organization's exempt purposes (other than by providing funds for such purposes)

information Regarding Taxable Subsidiaries and Disrel Entitles (See page 32 of the instructions ) (A) (B) (C) (D) (E) Name, address. and EIN of corporation . Percentage of Nature o1 activities Total income End-0f-year partnership, or disregarded entity ownership Interest assets

Information Regarding Transfers Associated with Per

(9) Did the organization . during the year, receive any funds, directly or Indir (b) Did the organization. during the year, pay premiums, directly or Vntw " 1/' Vac' In (lit file Form 8870 AND Form 4720 (see instructu Under penalties al perjury, l Axlare that l leave examined this return and belief, it is true qpnec],lnE complete Declaration of preparer (I Please Sign Sipna ure o1 oR Here ' John ' Type or pool name Phipa'ers - Paid Prsparers `i~° ,: u . Use Only a,eu

OMAHA. NE SCHEDULER Organization Exempt Under Section 501(c)(3) OMB NO 1545C (Form 990 or 990-EZ) (Except Private Foundation) and Section 501(e), 507(f), 501(k), 501(n), or Section 4947(a)(1) Nonexempt Charitable Trust '0o' Department Supplementary Information -(See separate instructions ) L L Imema) Revenue service MUST be Completed by the above organizations and attached to their Form 990 or 990-EZ Name of the organization Employer identification number Tabitha Inc 47-0377998 Compensation of the Five Highest Paid Employees Other Than Officers, Directors, and Trustees (See page 1 of the instructions List each one Ii there are none, enter "None ") (a) Name and address of each (b) Title and average (d) Contributions to (e) Expense account employee paid more than $50,000 hours per week I (c) Compensation I employee benefit plans 8 and other devoted to position deferred compensation allowances Dr Paul Plessman Director of Medical 6506 South 34th Street Services Lincoln NE 40 Hours

Darrell Sievert I Director of Information 3642 Washington Street Systems Lincoln NE

Helen Finch I Nursing Supervisor

Lincoln NE

Cynthia Thomas I RN Charge Nurse

Lincoln NE

Ann Harker I Nursing Supervisor

Lincoln NE

Total number of other employees paid

Eart"llA Compensation of the Five Highest Paid Independent Contractors for Professional Services (See page 2 of the instructions List each one (whether individuals or firms) If there are none, enter "None ")

(a) Name and address of each Independent contractor geld more than $50,000 ~ (b) Type of serve ~ (c) Compensation none

number of others receiving over

(trA) For Paperwork Reduction Act Notice, see the Instructions for Form 990 and Forth 990-EZ Schedule A (Form 990 or 990-EZ) 2002 aR'lll Statements About Activities (See page 2 of the instructions ) I Yes I No 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 m connection with the lobbying activities $ 0 (Must equal amounts on line 38, Part VI-A, or line i of Part VI-B ) Organizations that made an election under section 501(h) by filing Form 5768 must complete Part VI-A Other organizations checking "Yes," must complete Part VI-B AND attach a statement giving a detailed description of the lobbying activities 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 we answer to any question Is "Yes;" attach a detailed statement explaining the transactions ) a Sale, exchange, or teasing of property?

b Lending of money or other extension of credit 2b

c Furnishing of goods, services, or facilities 2c

d Payment of compensation (or payment or reimbursement of expenses if more than $1,000) see pan 11l/fom, 990 1 2d I X

e Transfer of any part of its income or assets 2e

3 Does the organization make grants for scholarships, fellowships, student loans, etc 7 (See NOTE below 4 Do you have a section 403(b) annuity plan for your employees Note. Attach a statement to explain how the organization determines that individuals or organizations receiving grants

,~a Reason for Non-Private Foundation Status (See pages 3 through 5 of the instructions )

The or anization 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 F-JA school section 170(b)(1)(A)(u) (Also complete Part V ) 7 DA hospital or a cooperative hospital service organization Section 170(b)(1)(A)(w) 8 F-]A Federal, slate, or local government or governmental unit Section 170(b)(1)(A)(v) 9 F-1 A medical research organization operated in conjunction with a hospital Section 170(b)(1)(A)(m) ENTER THE HOSPITAL'S NAME, CITY, AND STATE 70 [:]An organization operated for the benefit of a college or university owned or operated by a governmental unit Section 170(b)(1)(A)(rv) (Also complete the SUPPORT SCHEDULE in Part IV-A ) 17 a F~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 ) 17 b0A community trust Section 170(b)(1)(A)(vi) (Also complete the SUPPORT SCHEDULE in Part IV-A ) 12 X An organization that normally receives (1) MORE THAN 33 1/3% of its support from contributions. membership fees, and gross receipts from activities related to its chantable, etc , functions - subject to certain exceptions, and (2) NO MORE THAN 33 1/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization attar June 30, 1975 See section 509(a)(2) (Also complete the SUPPORT SCHEDULE In Part IV-A ) 13 DAn organization that is not controlled by any disqualified persons (other than foundation managers) and supports organizations descnbed in (1) lines 5 through 12 above, or (2) section 501(c)(4), (5), or (6), d they meet the test of section 509(a)(2) (See section 509(a)(3) )

14 [:]M organization organized and operated to test for public safety Section 509(a)(4) (See page 5 of the instructions ) Schedule A (Form 990 or 990-EZ) 2002 Support Schedule (Complete only if you checked a box online 10, 11, or 12 ) USE CASH METHOD OF ACCOUNTING Note You may use the worksheet m the instructions for from the accrual to the cash method of Calendar year (or fiscal year beginning in) 15 Gifts, grants, and contributions received (Do

17 Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities m any activity that is related to the

18 Gross income horn interest, dividends, amounts received from payments on securities loans (section 512(a)(5)), rents, royalties, and unrelated business taxable income (less section 511 taxes) from businesses acquired

19 Net Income from unrelated business

Tax revenues levied for the organization's benefit and either paid to it or expended on its behalf The value of services or facilities furnished to the organization by a governmental unit without charge Do not include we value of services or facilities generally furnished to the public without charge Other Income Attach a schedule Do not include gain or loss from sale of capital assets 647 .9501 606 .7941 566.413 1 567,471 Total of lines 15 through 22 20 956 686 1 S 484 573 18 040 504 18 262 09' Line 23 minus line 17 1 654 574 1 796 691 1 651 435 1 ,2' 5 03£ Enter I% 01 line 23 209 ,567 1 184 .846 1 180 .405 1 182 62' ORGANIZATIONS DESCRIBED ON LINES 10 OR 71 a Enter 2% of amount in column (e), line 24 b Prepare a list for your records to show the name of and amount contributed by each person (other than a governmental unit or publicly supported organization) whose total gifts for 1998 through 2007 exceeded the amount shown in line 26a DO NOT FILE THIS LIST WITH YOUR RETURN Enter the total of all these excess amounts c Total support for section 509(a)(1 ) test Enter line 24, column (e) d Add Amounts from column (e) for lines 18 0 19 0 22 0 26b 0 216 e Public support (line 26c minus line 26d total) 26e

ORGANIZATIONS DESCRIBED ON LINE 12 a for amounts included in Ilnes 15, 16, and 17 that were received from a *disqualified person,' prepare a list for your records to show the name o1, and total amounts received In each year horn, each disqualified person' DO NOT FILE THIS LIST WITH YOUR RETURN Enter the sum of such amounts for each year

(2001) 0 (2000) 0 (1999) 0 (1998) 0 b For any amount included in line 17 that was received horn each person (other than'dispualdied persons'), prepare a list for your records to show the name of, and amount received for each year, that was more than the LARGER of (1) the amount on line 25 for the year or (2) $5 000 (Include in the list organizations described in lines 5 through 11, as well as individuals ) DO NOT FILE THIS LIST WITH YOUR RETURN After computing the difference between the amount received and the larger amount described in (1) or (2), enter the sum of these differences (the excess amounts) for each year (2001) 0 (2000) 0 (1999) 0 (1998) 0

c Add Amounts horn column (e) for lines 15 3.765.291 16 0 17 69,416,115 20 0 21 0 d Add Line 27a total 0 and line 27b total 0 e Public support (line 27c total minus line 27d total) f Total support for section 509(a)(2) test Enter amount from line 23, column (e) 27f g PUBLIC SUPPORT PERCENTAGE (LINE 27E (NUMERATOR) DIVIDED BY LINE 27F (DENOMINATOR))

28 UNUSUAL GRANTS For an organrzatlon described in tine 70, 11, or 12 that received any unusual gents during 1998 through 2007, prepare a list for your records to show, for each year, the name of we contributor, the date and amount of the grant, and a brief description of the nature of the grant DO NOT FILE THIS LIST WITH YOUR RETURN Do not include these grants in line 75 Schedule A (Forth 990 or 990"EZ) 2002 Part V ~ Private School Questionnaire (See page 7 of the instructions ) (To be completed ONLY by schools that checked the box on line 6 in Part IV) nra

29 Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws, other governing instrument, or in a resolution of its governing body 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 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 penod if it has no solicitation program, in a way that makes the policy known to all parts of the general community it serves? 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's b Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory basis c Copies of all catalogues, brochures, announcements, and other written communications to the public dealing with student admissions, programs, and scholarships? d Copies of all material used by the organization or on its behalf to solicit contributions

If you answered *No" to any of the above, please explain (II you need mare space, attach a separate statement )

33 Does the organization discriminate by race in any way with respect to

a Students' rights or privileges?

b Admissions policies?

c Employment of faculty or administrative staff?

d Scholarships or other financial assistance

e Educational poliGes?

f Use of facilities?

g Athletic programs

h Other extracumcular activities?

If you answered 'Yes" to any of we above, please explain (If you need more space, attach a separate statement )

34 a Does the organization receive any financial aid or assistance from a governmental agency?

b Has the organization's right to such aid ever been revoked or suspended If you answered "Yes" to either 34a or b, please explain using an attached statement

35 Does the organization certify that it has complied with the applicable requirements of sections 4 01 through

Schedule A (Form 990 or 990-EZ) 2002 Schedule A Form 990 or 990.EZ 2002 Tabitha Inc 47-0377998 Page 5 Part .Vl-A:' Lobbying Expenditures by Electing Public Charities (See page 9 of the instructions ) (To be completed ONL Y by an eligible organization that filed Form 5768) nla Check a[:]if the organization belongs to an affiliated group Check b[:] d you checked "a" and "limited control" provisions apply (a) I (b) Limits on Lobbying Expenditures Affiliated pinup To be mmpieted totals for ALL electing (The term expenditures' means amounts paid or marred ) ri.nrr,Mn~~ 36 Total lobbying expenditures to influence public opinion (grassroots lobbying) 37 Total lobbying expenditures to influence a legislative body (dared lobbying) 38 Total lobbying expenditures (add lines 36 and 37) 39 Other exempt purpose expenditures 40 Total exempt purpose expenditures (add lines 38 and 39) 41 Lobbying nontaxable amount Enter the amount from the following table - It the amount on line 40 Is - The lobbying nontaxable amount Is - Not over E500,000 20°.6 0l the amount on line 40 Over $500,000 but not over $1,0D0,000 $00,000 plus 75% of the excess over $500,000 ', Over $7,000,000 but not over $7,500,000 $175.000 plus 10% of the excess over $1,000.000 y Over $1,500,000 but not over $17,000,000 $225,000 plus 5°h of the excess over $7,500,000 , Over $17,ODO,OOD $7,000,000 42 Grassroots nontaxable amount (enter 25% of line 41) 43 Subtract line 42 from line 36 Enter -0- d line 42 is more than line 36 44 Subtract line 41 from line 38 Enter-0- if line 41 is more than line 38

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below

Lobbying Expenditures During 4-Year Averaging Period Calendar year (or (e) I Ibl I (c) I (d) I (e)

Lobbying Activity by Nonelectlng Public Charities (For reporting only by organizations that did not complete Part VI-A) (See pag e 11 of the instructions ) 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 a Volunteers 6 Paid stall or management (Include compensation in expenses reported on lines c through h e 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 stalls, 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 ) ~~ 0 If "Yes" to any of the above also attach a statement -giving a detailed description of the lobbying activities Schedule A (Form 990 or 990-E2) 2002 Eait.Vll~, Information Regarding Transfers To and Transactions and Relationships With Nonchantable Exempt Organizations (See page 12 of the 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 FYes No (i) Cash (II) Other assets b Other transactions (i) Sales or exchanges of assets with a noncharitable exempt organization (II) Purchases of assets from a noncharitable exempt organization (id) Rental of facilities, equipment. or other assets (Iv) Reimbursement arrangements (v) Loans or loan guarantees (vi) Performance of services or membership or fundraising solicitations Sharing of facilities . equipment. mailing lists, other assets, or paid employees 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 reporting organization 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) (e) (d) Line no Amount involved Name of nonchantable exempt organization Descnption of transfers, transactions, and sharing arrangements

52 a 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 0 Yes X No

(a) (e) Name of orpanizahon Description of relationship

Schedule A (Form 990 or 990-EZ) 2002 TABITHA, INC 47-0377998 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENTI Part II. Line 42 - Depreciation Part IV. Line 57 - Land. Buildings 8 Equipment

Accumulated Depreciation Depreciation Allowed m Deprecation on Disposed Net Cost Prior Years Method Life Expense Assets Book Value

Land & Land Improvements $1,249,352 $568,676 SL 10-15 $32,889 S0 $647,787

Buildings and Fixed Equipment 12,700,493 7,405,519 SL 05-50 452,540 0 4,842,434

Equipment and Furnishings 4,712,423 3,107,213 SL 03-20 234,941 1,370,269

Construction in Progress 21,149 0 21,149

$18,683,417 11,081,408 $720,370 $0 $6,881,639

$ 11,801,778 Tabitha, Inc 47-0377998 2002 Form 990 Return of Organization Exempt from Income Tax

Statement 2 Part II, Line 43 (A) - Other Expenses

Total Program Services M 8 G Minor Equipment Purchase $ 54,623 $ 47,695 $ 6,928 Dues and Licenses $ 79,115 $ 54,598 $ 24,517 Advertising $ 185,026 $ 82,160 $ 102,866 Insurance $ 207,772 $ 207,772 Purchased Services $ 770,314 $ 716,263 $ 54,051 Misc $ 10,578 $ 21 8 10,557 Charity Allowances $ 437,586 $ 437,586 Bond Issuance Cost Amortization $ -

1,745,014 $ 1,546,095 $ 198,919 TABITHA, INC 47-0377998 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT 3: Part III. Statement of Program Service Accomplishments

Tabitha, Inc provides health care to the aged, infirmed, or otherwise unfortunate persons where no person shall be excluded based upon race, creed, color, or inability to pay Its mission is to provide physical, spiritual and emotional care to these persons and their families

Tabitha's client services division provides comprehensive in home, hospital, or in office health care planning to the communities m the 30 counties including and surrounding Lancaster county These services are provided at no charge The patients physical, environmental, social, and psychological factors are assessed, family and patient needs and goals determined, and available community services identified The patient and family then review the options and select the course of care

The nursing and rehabilitation center has 195 beds in operation and provides short and long term nursing care with rehabilitation programs including physical, occupational, and speech therapy Tabitha nursing and Rehabilitation Center operates units that provide Alzheimer's and Dementia services and hospice inpatient services Staff in these units have been specially trained to provide optimal care in these areas In addition, spiritual counseling, social workers, coordinated activities, and continual health care planning are provided at no additional cost to the patient In 2002 there were 67,694 patient care days, and 71% of these were for Medicare and Medicaid beneficiaries which resulted in $1,676,439 in unreimbursed charges

The home health agency provides licensed and certified home skilled nursing, home health aide, rehabilitation therapy (physical, speech, and occupational), and social worker visits to those whose injury or illness can be safely managed in the home Family members are trained to supplement professional care if desired The agency also provides health screening clinics and blood pressure checks in the communities it serves The home health agency provides services to communities in all or parts of 19 counties including and surrounding Lancaster County In 2002, the home health agency performed 46,763 visits with 929'0 of these for Medicare and Medicaid beneficiaries which resulted in $512,015 in unreimbursed charges There was $6385 in direct charity care and $65,636 in other unreimbursed charges

Tabitha's hospice program provides care for terminally ill persons and their families so that the patient is able to stay at home in most situations in a comfortable environment while giving other family members an opportunity to renew and enhance their relationship to the patient and each other The inter-disciplinary team approach allows comprehensive and intensive information-sharing, problem solving, and service delivery Services include a medical director, visiting nurses, social workers, home health aides, rehabilitation therapist (physical, occupational, and speech), spiritual counselors, consulting pharmacists and nutritionists, and bereavement counselors In addition to the above staff provided services, a full range of volunteer services are provided including respite care, transportation, childcare, light housekeeping, and companionship In 2002 hospice provided 27,866 patient care days to 603 patients Tabitha hospice provides care to those unable to pay through the Patient Care Fund The Patient Care Fund provided $55981 of care during 2002 TABITHA, INC 47-0377998 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT 3: Part III. Statement of Program Service Accomplishments

The meals on wheels program provides hot noon meals prepared by Tabitha staff and delivered by volunteers to residents in Lincoln and parts of Lancaster county who are recovering from an illness, regaining strength after a hospital stay, physically unable to prepare their own meals, or who need assistance to remain living independently It provides meals to any disabled or elderly person m need regardless of ability to pay In 2002 there were 112,261 meals provided at a $18,811 88 loss due to providing unreimbursed meals

The Walter is a HUD project in Lincoln that has 100 units and provides affordable (rents based on income), comfortable, and convenient housing in a secure setting with the maintenance and yard work provided Planned activities, health care planning services, transportation and 24 hour emergency monitoring to aid residents in case of distress are provided free of charge to the residents The Walter served 115 individuals in 2002

All Tabitha programs rely on volunteers to aid in providing an optimum level of care In 2002 total volunteer hours provided to Tabitha were 58,436 or the equivalent of close to 28 09 full time workers TABITHA, INC 47-0377998 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT 4: Part IV Balance Sheets. Line 58 - Other Assets

Beginning End of Year of Year

Restricted Deposits and Funded Reserves/Assets limited as to useless $422,922 $368,527 amounts required to meet current obligations

Funds Held by Bond Trustee 248,703 24,784

Other Assets, Net 53,392 76,434

Estimated Third-Party Payor Settlements - Medicare and Medicaid 109,765

834,182 09,739 TABITHA, INC 47-0377998 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT 5: Part IV. Line 64a - Tax Exempt Bond Liabilities

Beginning End of Year of Year

4 6% - 6 4% Tax-exempt Revenue Bonds, Series $205,000 $0 1992, issued 3115/92 by Hospital Authority No I of Lancaster County, Nebraska Principal is due annually in varying amounts from $135,000 in 1994 to $205,000 in March 2002 Interest is paid semiannually Proceeds were used to finance new construction and renovation of existing nursing facilities Original issue amount was $1,500,000 Form 8038 was filed 3/15/92 mere are no unexpended bond proceeds No part of the bond financed facility is used by a third party

5 OS°/, - 5 90%, tax-exempt Revenue Bonds, $1,389,000 $1,371,856 Series 2001, issued by Hospital Authority No 1 of Lancaster County, Nebraska Semi-annual installments of principal and interest are due on varying amounts from $8113 to $39,975 through March 15, 2017 Original issue amount was $600,000 Form 8038 was filed 6/1/98 There are no unexpended bond proceeds No part of the bond-financed facility is used by a third party

1,594,000 1,371,856 Tabitha, Inc 47-0377998 2002 Form 990 Return of Organization Exempt From Income Tax

Statement 6 Part IV, Line 64b-Mortgage and Other Notes Payable

Beginning End of Year of Year Department of Housing and Urban Development (HUD) 6 875%, mortgage note payable in monthly installments of $13,631, including principal and interest until September 2019 $ 1,670,592 $ 1,620,303 TABITHA, INC 47-0377998 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT 7' Part V - List of the 2002 Officers. Directors, and Trustees

Title and Time Contribution Devoted to to Benefit Expense Name and Address Position Compensation Plans Account

Keith Fickenscher President $ 127,935 17 $ 6,92914 None 5400 Carlisle Ct Full Time Lincoln NE 68516

Anne Frye Board Chair None None None 2750 Austin Dr Part Time Lincoln, NE 68506

Marvin Lyman Board Vice Chair None None None 4800 So 98th Street Part Time Lincoln, NE 68526

Jeff Holmberg Board SeclTreas None None None 5809 Fieldcrest Part Time Lincoln, NE 68512

Kenneth Broman Board Member 7411 Wren Cr Part Time None None None Lincoln NE 68506

Mark Bronder Board Member None None None 3241 Browning Part Time Lincoln, NE 68516

Mike Eisenhauer Board Member None None None 4331 South 38th Part Time Lincoln NE 68516

Roger Massey Board Member None None None 4120 Taliesm Dr Part Time Lincoln, NE 68520

Rev James Melang Board Member None None None 1844 East 12th St Part Time Fremont, NE 68025 Tabitha, Inc 47-0377988 2002 Form 990 Return of Organization Exempt from income Tax

Statement 8 Part VI, Line 80-Related Organizations

Tabitha Village, Inc Exempt 501 (C) (3) Tabitha Foundation Exempt 501 (C) (3) Tabitha Housing Corporation Exempt 501 (C) (3) Tabitha, Inc 47-0377998 2002 Forth 990 Return of Organization Exempt From Income Tax

Statement 9 Schedule A Part III, Line 3 8 4b

Tabitha, Inc makes no disbursements other than those associated with normal operations of the Nursing Home, Home Health Agency, Meals on Wheels, Hospice of Tabitha, and The Walter project

Tabitha, Inc grants scholarships to employees to become licensed as an LPN or RN Employees are reimbursed 100% of tuition, books, lab fees, and necessary supplies and tools up to $1200 00 per year with a $2500 00 maximum per individual The number of participants is limited to four LPN students and two RN students In 2002, $6377 45 was awarded for scholarships TABITHA, INC 47-0377998 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT 10: Schedule A. Part IV-A. Line 22 - Other Income

Year Description Amount

1998 Cafeteria, Vending and Catering Charges $106,935 Management Fees 252,025 Transportation 47,236 Maintenance Services 61,767 Other 99,515 $567,478

1999 Cafeteria, Vending and Catering Charges $103,035 Management Fees 272,220 Transportation 40,692 Maintenance Services 67,432 Other 83,034 $566,413

2000 Cafeteria, Vending, g meals, volunteer meals mow volunteers, and catering charges 104,072 00 Management Fees 289,419 00 Transportation 39,482 00 Maintenance Services 96,502 00 Other 77,319 $606,794

2001 Cafeteria, Vending, g meals, volunteer meals mow volunteers, and catering charges $ 126,092 00 Management Fees $ 311,724 00 Transportation $ 2,82300 Maintenance Services $ 102,650 00 Other $ 104,661 00 -647,95000 TABITHA FOUNDATION 47-0636199 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT II Schedule 990. Part VI, Line 90b

Tabitha Foundation employees are paid by common paymaster, Tabitha, Inc, FEIN 47-0377998 TABITHA FOUNDATION 47-0636199 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT 12 Schedule A. Part III. Line 4

The Tabitha Foundation can make disbursements exclusively for charitable, religious, educational, and scientific purposes, either directly or by contribution, to Tabitha, Inc for the sole benefit of Tabitha, Inc (an affiliated 501( c )(3) organization) TABITHA, INC 47-0377998 2002 FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX

STATEMENT 13' Part IV. Line 65 - Other Liabilities

2002 Tenant Security Deposits $ 25,107 00 Capital Leases $ 27,927 00 Capital Leases $ 35,471 00 Estimated Thud-Party Settlements $ 567,52800

Total $656,03300 mialkForm 8868 ( 12-2000) Page 2 o if yqu are filing for an Additional (not automatic) 3-Month Extension, complete only Part 11 and check this box 0- R Note : Only complete Part 11 d you have already been granted an automatic 3-month extension an a previously filed Form 8868 & If you are filing for an Automatic 1-Month Extension, complete only Part I (on page 1) Part II Additional not automatic 3-Month Extension of Time -Must File Original and One Co Type or Name of Exempt Organization Employer identification number print Tabitha, Inc . 47-0377998 File by the Number, street, and room or suite no If a P O box, see instructions For IRS use only ejaended euedate ror 9720 Randol h filing the City, tam or post office, state, and ZIP code For a foreign address, see instructions loin See nso-uchons ~ Lincoln, NE 68510 o Check type of return to be filed (File a separate application for each return) Form 990 0 Form 990-EZ 0 Form 990-T (sec 401(a) or 408(a) trust) E] Form 1041-A ~ Form 5227 0 Form 8870 [~ Form 990-BL C] Form 990-PF ~ Form 990-T (trustother than above) E) Form 4720 ~ Form 6069 STOP: Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868

Q 9 If the organization does not have an office or place of business in the United Slates, check this box w e If this is far a Group Return, enter the organization's four digit Group Exemption Number (GEN) If this is , o for the whole group, check this box Ili, 0 If it is for part of the group, check this box " hand attach a list with the names and p EINs of all members the extension is for ire 5x d I request an additional 3-month extension of time until November 17 , pp 03 W y 5 For calendar year ~ , or other tax year beginning , 20 - and ending , 20 - C> 6 If this tax year is for less than 12 months, check reason ~ Initial return [] Final return ~ Change in accounting period State indetail whyyouneed thaextension All information necessary to file a complete and accurate return is not yet available

8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits See instructions $ 0 0 0 b I( this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax payments made Include any prior year overpayment allowed as a credit and any amount paid previously with Form 8868 $ c Balance Due Subtract line Bb from line Ba Include your payment with this form, or, ii required, deposit with FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System) See instructions $ 0 00 Signature and Verification 7~gr penalties 01 penury I declare that 1 have e~omined this (ortn, including accampanrrq schedules end statements, and to the best of my kiwwledpe and belief A is true /rrecl, and complete and that 1 am authorized b prepare this form

lyiawre " ~~ /~...~ Tine " CPA Dale p~ 08/07/0 3 Noicet tp pplicant-To Be Completed by the IRS We have approved this application please at* this form 1o the organization's return We have not approved this application Ha"ver we have granted a 10-day grace period from the later of the date shown below or the due date of the organization's return (including any prior extensions) This grace penal a considered to be a valid extension of time for electio herwise required to be made on a limey velum Please attach thin tome to the organization's return r~~.r~, I~~ 0 We have not approved this application After considering the reasons stated in item 7, we can of gran~7 cB[teql+sisNbrdrf ~ n of time to file We are not granting a 10-day grace penal I (A 0 We cannot consider this application because d eras filed after the due date of the return for chic an ext nspn ~yaa,~p~est~` 0 Other yQ. AU~ 1 Y ~ 1~7'

,. ~ OGDEN, U? Director Date Alternate Marling Address - Enter the address if you want the copy of this application for an additional 3-month extension returned to an address different than the one entered above ,_,rrcn.~C1S`,~S APF'.

im, Johnson, Sestak & Zuist, LLP ATTN : Linda or no ) a P O Typo or Number and street (meiuae suns, room, a Or Eox number goof 8807 Indian Hills Drive Suite 300 City or town, province or state, and country postal or ZIP code)

Form 8868 (12 2000) S7F FE090°ibF7 ~of dsio ocoz siy~ y~ ~~ `Form$$6$ Application for Extension of Time To File an (December 2000) Exempt Organization Return OMB NO 15457709 Department M Yea Tnwiury mw,ri ae.enue sic. Iii, File a separate application for each return

" If you are filing for an Automatic 3-Month Extension, complete only Part I and check this box 1~ M " If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part II (on page 2 of this form) Note Do not compete Part 11 unless you have already been granted an automatic 3-month extension on a previously fled Form 8868 Part 1 Automatic 3-Month Extension of Time-Only submit original (no copies needed) Note: Form 99aT corporations requesting an automatic 6-month extension - check this box and complete Part 1 only All other corporations (including Form 99aC filers) must use Form 7004 to request an extension of time to ~Je income tax returns Partnerships. REMICs and trusts must use Form 8736 to request an extension of time to ale Form 7065, 1066, or 1041

Type or print Tabitha, Inc . 47-0377998 File by the Number street and room a suite no II a P O box, see instructions due date for filing your 4720 Randolph return See (-try, town or post ortice, stage, and ur caae ror a Foreign acaress see instructions instructions

Check type of return to be filed (file a separate application for each return) 0 Form 990 ~ Form 990-T (corporation) E3 Form 4720 0 Form 990-BL ~ Form 990-T (sec 401(a) or a08(a) trust) ~ Form 5227 0 Form 990-EZ ~ Form 990-T (trust other than above) ~ Form 6069 n Form 990-PF n Form 1041-A n Form 8870 0 If the organization does not have an office or place of business in the United States check this box 0. 0 " IT this is for a Group Return, enter the organizations four digit Group Exemption Number (GEN) If this is for the whole group, check this box ll~ E] If it is for part of the group, check this box fi~ [] and attach a list with the names and EINs of all members the extension will cover 1 I request an automatic month (6-month, for 990-T corporation) extension of time until Augus t 15 to file the exempt organization return for the organization named above The extension is for the organization's return for p, X calendar year 20 0? or " 0 tax year beginning , 20 -,and ending -, 20-

2 If this lax year is for less than 12 months, check reason [] Initial return [] Final return ~ Change in accounting period

3a If this application is for Form 990-BL, 990-PF, 99G-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits See instructions $ 0 .00 b If this application is for Form 990-PF or 990-T, enter any refundable credits and estimated tax payments made Include any prior year overpayment allowed as a credit $ c Balance Due. Subtract line 3b from line 3a Include your payment with this form, or, if required deposit with FTD coupon or, if required . by using EFTPS (Electronic Federal Tax Payment System) See instructions E 0 .00 Signature and Verification Under penalties of penury I declare that I have evamined this form including accompanying schedules and statements and to the best of my knowledge and belief it is true correct and complete, and that I am authorized to prepare this form

Date " S/13/0 3 For Act Note, see Form 8868 (12-1000)

I$R 57F FED9056F 7