IRS Form 990-PF for 2009 - Blue Shield of California Foundation

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FORM 990-PF Form 2220 (2009) Part IV Figuring the Penalty CALIFORNIA PHYSICIANS' SERVICE FDN (DBA BLUE SHIELD OF CALIFORNIA FDN) 94-2822302 Page 2 19 20 Enter the date of payment or the 15th day of the 3rd month after the close of the tax year, whichever is earlier (see instructions). (Form 990-PF and Form 990-T filers: Use 5th month instead of 3rd month.) ~~~~~~~~~~~~ Number of days from due date of installment on line 9 to the date shown on line 19 ~~~~~~~~~~~~~~~~~ 19 20 (a) (b) (c) (d) 21 Number of days on line 20 after 4/15/2009 and before 7/1/2009 ~~ 21 22 Underpayment on line 17 x Number of days on line 21 x 4% 365 ~~~ 22 $ $ $ $ 23 Number of days on line 20 after 06/30/2009 and before 10/1/2009 ~ 23 24 Underpayment on line 17 x Number of days on line 23 x 4% 365 ~~~ 24 $ $ $ $ 25 Number of days on line 20 after 9/30/2009 and before 1/1/2010 ~~ 25 26 Underpayment on line 17 x Number of days on line 25 X 4% 365 ~~~ 26 $ $ $ $ 27 Number of days on line 20 after 12/31/2009 and before 4/1/2010 ~ 27 28 Underpayment on line 17 x Number of days on line 27 X 4% 365 ~~~ 28 $ $ $ $ 29 Number of days on line 20 after 3/31/2010 and before 7/1/2010 ~~ 29 30 Underpayment on line 17 x Number of days on line 29 x *% 365 ~~~ 30 $ $ $ $ 31 Number of days on line 20 after 6/30/2010 and before 10/01/2010 ~ 31 32 Underpayment on line 17 x Number of days on line 31 x *% 365 ~~~ 32 $ $ $ $ 33 Number of days on line 20 after 9/30/2010 and before 1/1/2011 ~~ 33 34 Underpayment on line 17 x Number of days on line 33 x *% 365 ~~~ 34 $ $ $ $ 35 Number of days on line 20 after 12/31/2010 and before 2/16/2011 ~ 35 36 Underpayment on line 17 x Number of days on line 35 x *% 365 ~~~ 36 $ $ $ $ 37 Add lines 22, 24, 26, 28, 30, 32, 34, and 36 ~~~~~~~~~ 37 $ $ $ $ 38 Penalty. Add columns (a) through (d) of line 37. Enter the total here and on Form 1120; line 33; or the comparable line for other income tax returns * Use the penalty interest rate for each calendar quarter, which the IRS will determine during the first month in the preceding quarter. These rates are published quarterly in an IRS News Release and in a revenue ruling in the Internal Revenue Bulletin. To obtain this information on the Internet, access the IRS website at www.irs.gov. You can also call 1-800-829-4933 to get interest rate information. 38 $ 0. JWA Form 2220 (2009) 912802 01-05-10 27 09011109 794095 155930.0 2009.04050 CALIFORNIA PHYSICIANS' SERV 15593001
Form 8868 (Rev. 4-2009) ¥ If you are filing for an Additional (Not Automatic) 3-Month Extension, complete only Part II and check this box ~~~~~~~~~~ | Note. Only complete Part II if you have already been granted an automatic 3-month extension on a previously filed Form 8868. ¥ If you are filing for an Automatic 3-Month Extension, complete only Part I (on page 1). Part II Additional (Not Automatic) 3-Month Extension of Time. Only file the original (no copies needed). Type or print Name of Exempt Organization Employer identification number File by the extended due date for filing the return. See instructions. Check type of return to be filed (File a separate application for each return): Form 990 Form 990-EZ Form 990-T (sec. 401(a) or 408(a) trust) Form 990-BL X Form 990-PF Form 990-T (trust other than above) STOP! Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868. 8a b c CALIFORNIA PHYSICIANS' SERVICE FDN (DBA BLUE SHIELD OF CALIFORNIA FDN) 94-2822302 Number, street, and room or suite no. If a P.O. box, see instructions. 50 BEALE STREET, FOURTEENTH FLOOR City, town or post office, state, and ZIP code. For a foreign address, see instructions. SAN FRANCISCO, CA 94105 Form 1041-A Form 4720 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. If 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. Balance Due. Subtract line 8b from line 8a. 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. For IRS use only 8a $ Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete, and that I am authorized to prepare this form. Signature | Title | Date | 8b 8c Form 5227 Form 6069 CALIFORNIA PHYSICIANS' SRVC FDN - 50 BEALE STREET, FOURTEENTH FLOOR - SAN FRANCISCO, CA 94105 $ $ Page 2 Form 8870 ¥ The books are in the care of | Telephone No. | 415-229-5785 FAX No. | ¥ If the organization does not have an office or place of business in the United States, check this box~~~~~~~~~~~~~~~~ | ¥ If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) . If this is for the whole group, check this box | . If it is for part of the group, check this box | and attach a list with the names and EINs of all members the extension is for. 4 I request an additional 3-month extension of time until NOVEMBER 15, 2010. 5 For calendar year 2009 , or other tax year beginning , and ending . 6 7 If this tax year is for less than 12 months, check reason: State in detail why you need the extension Initial return Final return Change in accounting period THE TAXPAYER NEEDS ADDITIONAL TIME TO GATHER INFORMATION IN ORDER TO PREPARE AN ACCURATE TAX RETURN. Signature and Verification PRESIDENT AND CEO X 65,962. 100,000. 0. Form 8868 (Rev. 4-2009) 923832 05-26-09 28 09011109 794095 155930.0 2009.04050 CALIFORNIA PHYSICIANS' SERV 15593001
Page 1 and 2: November 9, 2010 California Physici
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TAX RETURN FILING INSTRUCTIONS CALI
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IRS Form 990-PF for 2009 - Blue Shield of California Foundation

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