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SECTION B: Name and Address or Other Establishments Operated By or Affiliated With Business or Nonprofit Organization (If None, type "None") <br />Name: <br />None <br />Address: <br />Type of Business or Activity: <br />SECTION C: Gross Receipts Determination for Business or Farm Operations <br />ITEM <br />BASE PERIOD <br />Gross Receipts or Gross Sales, Less Returns and Allowances <br />Year: 2009 <br />Year: 2010 <br />Average: <br />$16,250.00 <br />$21,175.00 <br />$18,712.50 <br />SECTION D: General Tax Information (NOT to be completed by Nonprofit Organizations) <br />Name(s) Used on Income Tax Retum(s) <br />Xavier Rodriguez <br />Tax Returns Filed with Director of Internal Revenue In: <br />YEAR <br />CITY <br />STATE <br />Employer Identification Number(s) Shown on Tax Return(s) <br />2009 <br />Santa Ana <br />CA <br />Principal Business Activity Type Reported on Tax Return(s) <br />Home Health Care -Natural Herbs <br />2010 <br />Santa Ana <br />CA <br />SECTION E: Computation of Average Net Earnings or Net Revenues for Base Period <br />ITEM (complete appropriate table) <br />BASE PERIOD <br />Year: 2009 <br />Year: 2010 <br />Average: <br />TABLE I: INDIVIDUAL OR SOLE PROPRIETOR (Relates to IRS Form 1040) <br />(1)Non Profit(or Loss) Before Taxes from IRS Form 1040 <br />$10,650.00 <br />$15,625.00 <br />(2) Compensation Paid to Omer, Owners Spouse and Dependents <br />(List names and amounts In Remarks) <br />(3) Net Earnings (Add lines(1) and (2) <br />$10,650.00 <br />$15,625.00 <br />$13,137.50 <br />TABLE II: CORPORATION (Relates to IRS Form 1120 or 1120-S) <br />(4) Taxable Income (form 1120) or Ordinary Income (form 1120-S) <br />(5) Compensation Paid to Principal Stockholders, Their Spouses and Dependents <br />(List names and amounts In Remarks) <br />(6) Net Earnings (Add lines (4) and (5)) <br />$0.00 <br />$0.00 <br />$0.00 <br />TABLE III: PARTNERSHIP (Relates to IRS Form (1065) <br />(7) Ordinary Income (or Loss) Before Taxes from IRS Form 1065 <br />(6) Compensation Paid to Principal Pannem, Their Sppuses and Dependents <br />(List names and amounts in Remarks) <br />(9) Net Earnings (Add lines (7) and (8)) <br />$0.00 <br />$0.00 <br />TABLE IV: NONPROFIT ORGANIZATION <br />(10) Annual Gross Revenues: <br />(11) Administrative Expenses: <br />(12) Net Revenues (Subtract line (11) from line (10) <br />$0.00 <br />$0.00 <br />$0.00 <br />REMARKS: <br />Based on Centro Natural de Salud's annual net earnings they are eligible for a fixed payment in lieu of a payment for actual reasonable moving and related <br />expenses totaling $13,137.50. <br />Overland, Pac fc & Curler, Inc. Page 2 of 2 <br />=SC-05 (4/04) <br />