U.S. Income Tax Return for an S Corporation Do not file this form unless the corporation has filed or is

attaching Form 2553 to elect to be an S corporation. ► See separate instructions.

OMB No. 1545-0130

2009

For calendar year 2009 or tax year beginning , 2009, ending , 20

A S election effective date

07-16-2002 Use IRS label.

Other-wise, print or type.

Name Number, street, room/suite no. City/town, state, & Zip code

Commission On Health Care Certification Inc. 13801 Village Mill Drive Midlothian VA 23113

D Employer ID no.

22-3859071 B Business activity

code number (see instructions)

541990

E Date incorporated

07-16-2002 F Total assets (see inst.)

$ 824 C Check if Sch. M-3

attached

H Check if: (1)

-

Final return _ (2) 0 Name change (3) 0 Address change

(4) _ Amended return (5) 0 S election termination or revocation

I Enter the number of shareholders who were shareholders during any part of the tax year

Caution. Include only trade or business income and expenses on lines la through 21. See the instructions for more information.

-zc

.)02

w

1a

2

3

4

5

6

Gross receipts or sales 172 297 b Less retums and allowances r CBal 111. 1C 172,297 Cost of goods sold (Schedule A, line 8)

Gross profit. Subtract line 2 from line 1c

Net gain (loss) from Form 4797, Part II, line 17 (attach Form 4797)

Other income (loss) (see instructions -- attach statement)

Total income (loss). Add lines 3 through 5 ►

2

3 172,297

5

6 172,297 7 Compensation of officers 7

8 Salaries and wages (less employment credits) 8

9 Repairs and maintenance 9

10 Bad debts 10

11 Rents 11 6,232 12 Taxes and licenses 12

13 Interest 13 E-. 14 Depreciation not claimed on Schedule A or elsewhere on return (attach Form 4562) 14

15 Depletion (Do not deduct oil and gas depletion.) 15

16 Advertising 16 6,453 17 Pension, profit-sharing, etc., plans 17

18 Employee benefit programs 18

19 Other deductions (attach statement) 19 71,919 20 Total deductions. Add lines 7 through 19 ► 20 84

, 604

21 Ordinary business income (loss).Subtract line 20 from line 6 21 87, 693 I

1-a

x a

zo

o_<>

-2Luz

i-u)

22a

b

Excess net passive income or LIFO recapture tax (see instructions)...

Tax from Schedule D (Form 1120S)

22a

22b

c Add lines 22a and 22b (see instructions for additional taxes) 22c 0

23a

b

c

2009 estimated tax payments and 2008 overpayment credited to 2009

Tax deposited with Form 7004

Credit for federal tax paid on fuels (attach Form 4136)

23a

23b

23c

d Add lines 23a through 23c 23d 0

24 Estimated tax penalty (see instructions). Check if Form 2220 is attached ► I 24

25 Amount owed. If line 23d is smaller than the total of lines 22c and 24, enter amount owed 25 0

26 Overpayment. If line 23d is larger than the total of lines 22c and 24, enter amount overpaid 26

27 Enter amount from line 26 Credited to 2010 estimated tax ► 0 Refunded ► 27 0

D E D U C T

0 N S

G Is the corporation to be an S corporation beginning with this tax year? J Yes IN No If "Yes," attach Form 2553 if not already filed

Under penalties of perjury, I deelerelfret have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

President Title

Sign Here

May the IRS discuss this return with the preparer shown below

(see inst.)? g Yes n No

Paid Preparer's Firm's name (or Kevin J Perlowski CPA Use Only yours if self-employed), r 9409 Hull Street Rd

address, and ZIP code Richmond, VA 23236 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

JVA 09 1120S12 TWF 33172 Copyright Forms (Software Only) - 2009 TW

Preparer's

signature

Date

07-20-2011 Check if self-

employed n Preparer's SSN or PTIN

P00238214 EIN 54-1761867 Phone no.

Form 1120S (2009)

Form 1120S Department of the Treasury Internal Revenue Service

#1

#2

Date

' Commission On Health Care 22-3859071 Form 1120S (2009) Page 2

1

2

3

4

5

6

7

8

Schedule A Cost of Goods Sold (see instructions)

Inventory at beginning of year 1

Purchases 2

Cost of labor 3

Additional section 263A costs (attach statement) 4

Other costs (attach statement) 5

Total. Add lines 1 through 5 6

Inventory at end of year 7

Cost of goods sold. Subtract line 7 from line 6. Enter here and on page 1, line 2 8

9a Check t i i l i l used f d th all a methods useor valuing closing inventory: W 0 Cost as described in Regulations section 1.471-3

(ii)_ Lower of cost or market as described in Regulations section 1.471-4

(iii) Other (Specify method used and attach explanation.) ► ■••••

b Check if there was a writedown of subnormal goods as described in Regulations section 1.471-2(c) ► c Check if the LIFO inventory method was adopted this tax year for any goods (if checked, attach Form 970) ► d If the LIFO inventory method was used for this tax year, enter percentage (or amounts) of closing

inventory computed under LIFO

9d

e If property is produced or acquired for resale, do the rules of section 263A apply to the corporation?

f Was there any change in determining quantities, cost, or valuations between opening and closing inventory?

If "Yes," attach explanation.

Schedule B Other Information (see instructions) Yes No

1 Check

2 See

a

accounting method: a Cash b 11 Accrual c 11

the instructions and enter the: Business activity ► Professional , Scien b Product or service

Other (specify)►

► All other profession 3 At the end of the tax year, did the corporation own, directly or indirectly, 50% or more of the voting stock of a domestic

corporation? (For rules of attribution, see section 267(c).) If "Yes," attach a statement showing:(a) name and employer

identification number (EIN), (b) percentage owned, and (c) if 100% owned, was a QSub election made? X

4 Has this corporation filed, or is it required to file, a return under section 6111 to provide information on any reportable

transaction? X

5 Check this box if the corporation issued publicly offered debt instruments with original issue discount ► 1

If checked, the corp. may have to file Form 8281, Information Return for Publicly Offered Original Issue Discount Instruments.

6 If the corporation: (a) was a C corporation before it elected to be an S corporation or the corporation acquired an asset with

a basis determined by reference to its basis (or the basis of any other property) in the hands of a C corporation and (b) has

net unrealized built-in gain (defined in section 1374(d)(1)) in excess of the net recognized built-in gain from prior years,

enter the net unrealized built-in gain reduced by net recognized built-in gain from prior

years ► $

7 Enter the accumulated earnings and profits of the corporation at the end of the tax year. $

8 Are the corporation's total receipts (see instructions) for the tax year and its total assets at the end of the tax year less

than $250,000? If "Yes," the corporation is not required to complete Schedules L and M-1 X 'Schedule K] Shareholders' Pro Rata Share Items Total amount

—Z

OO

SL

LI —

10

co

in

1 Ordinary business income (loss) (page 1, line 21) 1 87,693 2 Net rental real estate income (loss) (attach Form 8825) 2

3a Other gross rental income (loss)

b Expenses from other rental activities (attach statement)

3a

3b

c Other net rental income (loss). Subtract line 3b from line 3a 3c

4 Interest income 4

5 Dividends: a Ordinary dividends

b Qualified dividends 1 5b 1

5a

6 Royalties 6

7 Net short-term capital gain (loss) (attach Schedule D (Form 1120S)) 7

8a Net long-term capital gain (loss) (attach Schedule D (Form 1120S))

b Collectibles (28%) gain (loss)

c Unrecaptured section 1250 gain (attach statement)

8b

8a

8c

9 Net section 1231 gain (loss) (attach Form 4797) 9

10 Other income (loss) (see instructions) Type ► 10

Yes

Yes

No

No

JVA

09 1120S12 TWF 33173

Copyright Forms (Software Only) - 2009 TW

Form 1120S (2009)

' Commission On Health Care 22-3859071 Form 1120S (2009)

Page 3

Deduc-tions

Shareholders' Pro Rata Share Items (continued) Total amount

11 Section 179 deduction (attach Form 4562)

12a Contributions

b Investment interest expense

c Section 59(e)(2) expenditures (1) Type ► (2) Amount ►

11

12a 560 12b

12c(2)

d Other deductions (see instructions) Type ► 12d

Credits

13a Low-income housing credit (section 42(j)(5))

b Low-income housing credit (other)

c Qualified rehabilitation expenditures (rental real estate) (attach Form 3468)

d Other rental real estate credits (see instructions) Type ►

13a

13b

13c

13d

e Other rental credits (see instructions) Type ► 13e

f Alcohol and cellulosic biofuel fuels credit (attach Form 6478)

g Other credits (see instructions)... Type ► 13f 13g

Foreign Trans- actions

14a Name of country or U.S. possession ► 14b b Gross income from all sources

c Gross income sourced at shareholder level

Foreign gross income sourced at corporate level

d Passive category

e General category

f Other (attach statement)

Deductions allocated and apportioned at shareholder level

g Interest expense

h Other

Deductions allocated and apportioned at corporate level to foreign source income

i Passive category

j General category

k Other (attach statement)

Other information

14c

14d

14e

14f

14g

14h

14i

14j

14k

141 I Total foreign taxes (check one): ► I Paid I Accrued

m Reduction in taxes available for credit (attach statement)

n Other foreign tax information (attach statement)

14m

Altern- ative Mini- mum Tax (AMT) Items

15a Post-1986 depreciation adjustment

b Adjusted gain or loss

c Depletion (other than oil and gas)

d Oil, gas, and geothermal properties--gross income

e Oil, gas, and geothermal properties--deductions

f Other AMT items (attach statement)

15a

15b

15c

15d

15e 15f

Items Affect- mg Share-holder Basis

16a Tax-exempt interest income

b Other tax-exempt income

c Nondeductible expenses

d Property distributions

e Repayment of loans from shareholders

16a

16b

16c 703 16d 86,430 16e

Other Inform- ation

17a Investment income

b Investment expenses

c Dividend distributions paid from accumulated earnings and profits

d Other items and amounts (attach statement)

17a

17b

17c

Recon- :illation

18 Income/loss reconciliation. Combine the amounts on lines 1 through 10 in the far right

column. From the result, subtract the sum of the amounts on lines 11 through 12d and 141 18 87 , 133 JVA

09 1120S34

TWF 33174

Copyright Forms (Software Only) - 2009 TVV

Form 11 ZUS (2009)

Commission On Health Care 22-3859071 Form 1120S (2009) Page 4

Schedule L I Balance Sheets per Books Beginning of tax year End of tax year

1

2a

b 3

4

5

6

7

8

9

10a

b

11a

b 12

13a

b 14

15

16

17

18

19

20 21

22

23

24

25

26 27

Assets Cash

Trade notes and accounts receivable .

Less allowance for bad debts Inventories U.S. government obligations

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 depreciable assets

Less accumulated depreciation

Depletable assets

Less accumulated depletion

Land (net of any amortization)

Intangible assets (amortizable only)

Less accumulated amortization

Other assets (attach statement)

Total assets Liabilities and Shareholders' Equity

Accounts payable

Mortgages, notes, bonds payable in less than 1 yr

Other current liabilities (attach statement)

Loans from shareholders

Mortgages, notes, bonds payable in 1 year or more

Other liabilities (attach statement)

Capital stock Additional paid-in capital

Retained earnings Adjustments to shareholders' equity (attach stmt.)

Less cost of treasury stock

Total liabilities and shareholders' equity

(a) (b) (c) (d)

324 324

) ( )

20,838 20,838 ( 20,838 ) ( 20,838 )

( ) ( )

( ) ( ) 500 500 824 824

824 824

( ) ( ) 824 824

Schedule M-1 Reconciliation of Income (Loss) per Books With Income (Loss) per Return Note: Schedule M-3 required instead of Schedule M-1 if total assets are $10 million or more -- see instructions

1 Net income (loss) per books 2 Income included on Schedule K, lines 1, 2,

3c, 4, 5a, 6, 7, 8a, 9, and 10, not recorded on books this year (itemize):

3 Expenses recorded on books this year not included on Schedule K, lines 1 through 12 and 141 (itemize):

a Depreciation $

b Travel and entertainment $ 703

4 Add lines 1 through 3

86,430

703 87,133

5 Income recorded on books this year not included on Schedule K, lines 1 through 10 (itemize):

a Tax-exempt interest $

6 Deductions included on Schedule K, lines 1 through 12 and 141, not charged against book income this year (itemize):

a Depreciation $

7 Add lines 5 and 6

8 Income (loss) (Schedule K, line 18). Line 4 less line 7 87 133 nt, and

Shareholders' Undistributed Taxable Income Previously axed (see instructions) Schedule M-2 Analysis of Accumulated Adjustments Account, Other Adjustments Accou

(a) Accumulated adjustments account

(b) Other adjustments account

(c) Shareholders' undistributed taxable

income previously taxed

1 Balance at beginning of tax year

2 Ordinary income from page 1, line 21

3 Other additions 4 Loss from page 1, line 21

5 Other reductions

6 Combine lines 1 through 5 7 Distributions other than dividend distributions

8 Balance at end of tax year. Subtract line 7 from line 6 . .

824 87,693

1,263#5 ) 87,254 86,430

824 Form 1120S (2009) JVA 09 1120534 TWF 33175 Copyright Forms (Software Only) - 2009 TW

2009 SCHEDULE M-1 EXPLANATION ATTACHMENT

Commission On Health Care 22-3859071

Computation of Net Income (Loss) Per Books

Form 1120, Schedule M-1, Line 1

Income (loss) (Schedule M-1, line 8) carries from Form 1120S, page 3, line 18 87,133

Increases:

Deductions on return not charged against book income (Schedule M-1, line 6)

Income recorded on books not included on return (Schedule M-1, line 5)

Decreases:

Expenses recorded on books not included on return (Schedule M-1, line 3)

Income subject to tax not recorded on books (Schedule M-1, line 2)

Computed net income (loss) per books (Schedule M-1, line 1) 86,430

703

JVA Copyright Forms (Software Only) - 2009 7VV M0709A 09_CSM1

2009 DETAIL STATEMENTS Commission On Health Care 22-3859071 Page 1

STATEMENT #1 - Rent On Business Property (1120S PG1 - DED LINE 11)

Rent On Business Property: Rent - Real Property

6,232 TOTAL Rent On Business Property

6,232

TOTAL CARRIED TO 1120S PG1 - DED LINE 11 6,232

STATEMENT #2 - Other Deductions (1120S PG1 LINE

Other Deductions:

19)

Bank Charges 3,404 Legal & Professional 1,000 Licenses & Permits 339 Meals & Entertainment 50% 703 Office Supplies 14,485 Postage 1,795 Telephone 2,861 Travel 20,378 Utilities 3,260 Miscellaneous 6,920 Computer/IT Expenses 9,095 Card Fees 1,979 C/L 1,500 Training/Eductaion 4,200

TOTAL Other Deductions 71,919

TOTAL CARRIED TO 1120S PG1 LINE 19 71,919

STATEMENT #3 - CONTRIBUTIONS (1120S PG 3 LINE 12a)

Code A - Cash Contributions (50%) 560

TOTAL CARRIED TO 1120S PG 3 LINE 12a 560

STATEMENT #4 - NONDEDUCTIBLE EXPENSES (1120S PG 3 LINE 16c)

Code C - Disallowed Meals/Entertainment 703

TOTAL CARRIED TO 1120S PG 3 LINE 16c 703

STATEMENT #5 - Other Reductions (1120S PG 4 M-2 LINE 5(a))

Charitable Contributions 560 Disallowed Meals & Entertainment 703

TOTAL CARRIED TO 1120S PG 4 M-2 LINE 5(a) 1,263

JVA Copyright Forms (Software Only) - 2009 TW C1005D 09LSSTMT

# 1

671109 n Final K-1 n Amended K-1 OMB No. 1545-0130

Shareholder's Share of Current Year Inc., Deductions, Credits, and Other Items Part III

Schedule K-1

2009 (Form 1120S)

13 Credits Department of the Treasury For calendar year 2009, or tax Internal Revenue Service

year beginning , 2009

ending , 20

Shareholder's Share of Income, Deductions,

Credits, etc. ► See page 2 and separate instructions.

1 Ordinary business inc. (toss)

87,693 2 Net rental real estate inc (loss)

3 Other net rental income (loss)

Information About the Corporation 4 Interest income

Part I

A Corporation's employer identification number

22-3859071 5a Ordinary dividends

14 Foreign transactions B Corporation's name, address, city, state, and ZIP code

Commission On Health Care Certification Inc. 13801 Village Mill Drive Midlothian VA 23113

5b Qualified dividends

6 Royalties

7 Net short-term cap. gain (loss)

8a Net long-term cap. gain (loss) C IRS Center where corporation filed return

CINCINNATI

Information About the Shareholder 8b Collectibles (28%) gain (loss)

Part II

8c Unrecaptured sec 1250 gain D Shareholder's identifying number

224-78-6225 E Shareholder's name, address, city, state, and ZIP code 9 Net section 1231 gain (loss)

15 Alternative min tax (AMT) items 10 Other income (loss)

Virgil R. May 13325 Queensgate Rd VA Midlothian 23114

F Shareholder's percentage of stock ownership for tax year 100.0000%

For IRS Use Only

11 Section 179 deduction

12 Other deductions

560

16 Items affecting

shareholder basis

C 703 D 86,430

17 Other information

* See attached statement for additional information.

For Paperwork Reduction Act Notice, see Instructions for Form 1120S. Schedule K-1 (Form 1120S) 2009

JVA 09 120SK112 TWF 32983 Copyright Forms (Software Only) - 2009 TW

2009 Virginia Pass-Through Entity Form 502 Return of Income and Return of Department of Taxation Nonresident Withholding Tax P.O. Box 1500

Richmond, VA 23218-1500

FISCAL or SHORT Year Filer: Beginning Date •

fl

II Check if:

Initial return

Ending Date •

Name change Address change Change in fiscal year

Federal Employer ID Number

22-3859071 Official Use Only

Entity Name

Commission On Health Care Number and Street

13801 Village Mill Drive Address continued

City or Town, State and ZIP Code

Midlothian VA 23113 Date of Formation

07-16-2002 Date Operations Began in Virginia

07-16-2002 State or Country Where Incorporated or Organized

VA Entity Type (Enter Code -- See instructions)

SC NAICS

541990 Description of Business Activity

Professional, Scientif

El Amended return

Electing large partnership

Numbers And Types Of Owners

Final return

7 Subject to bank franchise tax

Unified nonresident return filed

Count all owners that were issued a federal Schedule K-1 for the taxable year and enter:

a. The Total Number Of Owners (Include individuals and any other entity types) a. 1 •

b. The Total Number Of Nonresident Owners (See Instructions) b. •

c. Total Amount Withheld for Nonresident Owners (Total of "line e" from all VK-1's with withholding amounts) , c. .00 •

d. If entity is exempt from withholding enter exemption code (see instructions) d. •

Distributive Or Pro Rata Income And Deductions See instructions.

1. Total Of Taxable Income Amounts 1. 87,693 .00 • 2. Total Of Deductions 2. 560 .00 •

3. Tax-exempt Interest Income 3. .00 •

Allocation And Apportionment

4. Income Allocated To Virginia (From Schedule 502A, Part A, Line 2) 4. .00 •

5. Income Allocated Outside Of Virginia (From Schedule 502A, Part A, Line 3e) 5. .00 •

6. Apportionable Income (From Schedule 502A, Part A, Line 4) 6. 87,693 .00 •

7. Virginia Apportionment Percentage (From Schedule 502A, Part B or Part C or 100%) 7. 100.0000 % • Virginia Additions -- See Schedule 502ADJ For Other Additions

8. Fixed-date Conformity -- Depreciation 8. .00 •

9. Fixed-date Conformity -- Other 9. .00 •

10. Net Income Tax Or Other Tax Used As A Deduction In Determining Taxable Income (See Instructions) 10. .00 •

11. Interest On Municipal Or State Obligations Other Than From Virginia 11. .00 •

12. Total additions from attached Schedule 502ADJ, Section A, line 5 12. .00 •

13. Total additions (Add lines 8-12) 13. .00 •

Virginia Subtractions -- See Schedule 502ADJ For Other Subtractions

14. Fixed-date Conformity -- Depreciation 14. .00 •

15. Fixed-date Conformity -- Other 15. .00 •

Va. Dept. Of Taxation 2601015 502 (Rev 08/09)

•

•

•

•

1043 09 VA5021 -rwF 36240 Copyright Forms (Software Only) - 2009 TVV

2009 Va. Name Commission On Health Care Form 502 Federal Employer ID Number 22-3859071 Page 2 iii

16. .00

17. .00 • 18. .00 •

19. .00 •

20. .00 •

1. .00 •

2. .00 • 3. .00 •

4. .00 •

5. .00 •

6. .00 • 7. .00 •

8. .00 •

9. .00 •

10. .00 •

11. .00 •

12. .00 •

13. .00 •

14. .00 •

15. .00 •

16. .00

16. Income From Obligations Of The United States 17. Total Subtractions from attached Schedule 502ADJ, Section B, line 5

18. Total Subtractions (Add lines 14-17)

Virginia Tax Credits And Related Information From Schedule 502ADJ

19. Total nonrefundable credits (From Section C, Line 26 from attached Schedule 502ADJ)

20. Total refundable credits (From Section C, line 32 from attached Schedule 502ADJ)

Reconciliation of Withholding, Penalties, Interest and Overpayment/Tax Due

Section 1: Withholding Payment Reconciliation 1. Total withholding tax due for nonresident owners

2. Total withholding tax paid

3. Overpayment (If line 2 is greater than line 1, subtract line 1 from line 2)

4. Balance of tax due (If line 2 is less than line 1, subtract line 2 from line 1)

Section 2: Penalty and Interest Charges on Withholding Tax 5. Extension penalty (may apply if the difference between line 1 and line 2 is more than 10 percent of line 1)

6. Late filing penalty (will apply if there is a balance due on line 4 and Form 502 is being filed more than six months

after the original due date)

7. Interest (may apply if there is a balance due on line 4)

8. Total penalty and interest charges due (add lines 5, 6, and 7)

Section 3: Penalty for Late Filing of Form 502 9. If Form 502 is being filed more than six months after the original due date, or more than 30 days after the federal

extended due date, enter $1,200

Section 4: Disposition of Overpayment

10. Net overpayment. Subtract lines 8 and 9 from line 3. If lines 8 and 9 exceed line 3, go to line 13 below

11. Amount of overpayment to be credited to 2010

12. Amount of overpayment to be refunded

Section 5: Total Payment Due With Form 502 13. Balance of tax due from line 4, or total of lines 8 and 9 less line 3, whichever is applicable

14. Penalty and interest charges on withholding tax from line 8 if not included on line 13

15. Late filing penalty from line 9 if not included on line 13

16. Total payment due (Add lines 13, 14, and 15)

By checking the box to the right, I (we) authorize the Department of Taxation to discuss this return with the undersigned preparer.

I, the undersigned owner and authorized representative of the pass-through entity for which this return is made, declare under the penalties

provided by law that this return (including any accompanying schedules, statements and attachments) has been examined by me and is, to the

best of my knowledge and belief, a true, correct, and complete return, made in good faith, for the taxable year stated, pursuant to the tax laws of

the Commonwealth of Virginia. A preparer other than the authorized representative declares the same, and such declaration is based on all

information of which he or she has any knowledge.

President (Signature and Phone Number of Owner or Authorized Representative) (Title) (Date)

9409 Hull Street Rd Richmond, VA 23236 07-20-2011

(Individual or Firm, Signature of Preparer, Phone Number, and Address) (Date)

Preparer's FEIN, PTIN or SSNPO 0238214 • Approved Vendor Code 10 43 • Attach a copy of your Federal Return and Schedule VK-1 for each owner to the Form 502.

Do Not Attach Form 765 With This Return -- Mail to Address On Form 765

1043 09 VA5022 TWF 36241 Copyright Forms (Software Only) - 2009 TW

2009 VIRGINIA Schedule VK-1 (Form 502) Check If -

Final

Amended Return •

Owner's Share of Income And Virginia Modifications And Credits

Check Here if Owner is Participating in an Individual Unified Nonresident Return •

ui Owner Information

Pass-Through Entity (PTE) Information Name

Virgil R. May FEIN or SSN

224-78-6225 Name Commission On Health Certification Inc.

FEIN

22-3859071 Address Address Tax Year End Date

12-31-09 Address

13325 Queensgate Rd Address

13801 Village Mill Drive City or Town, State And ZIP Code

VA Midlothian 23114 City or Town, State And ZIP Code

Midlothian VA 23113

Additional Owner Information

a. Date Owner Acquired Interest In The Pass-Through Entity (MM/DD/YYYY) •

b. Owner's Entity Type (Enter code; see instructions) RES • c. Owner's Participation Type (Enter code; see instructions) SHR •

d. Owner's Participation Percentage (Example: 47.35% -- see instructions.) 100 . 00 % •

e. Amount Withheld by PTE for Owner •

f. If Owner or Entity is exempt from withholding enter exemption code (see instructions) •

Distributive or Pro Rata Income and Deductions

See instructions.

1. Total of Taxable Income Amounts 1. 87,693 .00.

2. Total of Deductions 2. 560 .00 •

3. Tax-exempt Interest Income 3. .00 •

Allocation and Apportionment

4. Income Allocated To Virginia (Owner's Share From PTE's Schedule 502A, Part A, Line 2) 4. .00 •

5. Income Allocated Outside Of Virginia (Owner's Share From PTE's Schedule 502A, Part A, Line 3e) 5. .00 •

6. Apportionable Income (Owner's Share From PTE's Schedule 502A, Part A, Line 4) 6. 87,693 .00•

7. Virginia Apportionment Percentage (From PTE's Schedule 502A, Part B or Part C or 100%) 7. 100.0000 %•

Virginia Additions -- Owner's Share

8. Fixed-date Conformity -- Depreciation 8. .00

9. Fixed-date Conformity -- Other 9. .00

10. Net Income Tax Or Other Tax Used As A Deduction In Determining Taxable Income (See Instructions) 10. .00

11. Interest On Municipal Or State Obligations Other Than From Virginia 11. .00

12. Other additions (see instructions for addition codes)

Code Amount Code Amount

12a .00 12b .00

12c

.00 12d

.00

13. Total additions (add lines 8-11 and 12a-12d)

13. .00 •

Virginia Subtractions -- Owner's Share

14. Fixed-date Conformity -- Depreciation 14.

15. Fixed-date Conformity -- Other 15.

16. Income From Obligations Of The United States 16.

17. Other subtractions (see instructions for subtraction codes)

Code Amount Code Amount

17a .00 17b .00

17c .00 17d .00

18. Total Subtractions (Add lines 14-16 and 17a-17d) 18.

Va. Dept. Of Taxation 2601024 VK-1 (Rev 10109)

1043 09 VAVK11 TWF 36245 Copyright Forms (Software Only) - 2009 TW

.00

.00

.00

.00 •

VA Schedule VK-1 (10/09)

2009 Virginia Schedule VK-1 Page 2

in

Owner Federal Employer ID Number or SSN 224-78-6225

PTE Federal Employer ID Number22 - 3859073.

SECTION C -- Virginia Tax Credits Nonrefundable Credits

1. State Income Tax Paid (See instructions) 1. .00 2. Neighborhood Assistance Act Credit 2. .00 3. Enterprise Zone Act General Tax Credit 3. .00 4. Enterprise Zone Act Zone Investment Tax Credit 4. .00 5. Reserved for future use 5. .00 6. Conservation Tillage Equipment Credit 6. .00 7. Bio-Diesel Credit 7. .00 8. Fertilizer & Pesticide Application Equipment Credit 8. .00

9. Recyclable Materials Processing Equipment Credit 9. .00 10. Rent Reduction Program Credit 10. .00 11. Vehicle Emissions Testing Equipment Credit 11. .00 12. Major Business Facility Job Tax Credit 12. .00

13. Clean Fuel Vehicle Job Creation Tax Credit 13. .00

14. Day-care Facility Investment Tax Credit 14. .00

15. Low-income Housing Tax Credit 15. .00

16. Agricultural Best Management Practices Tax Credit 16. .00

17. Worker Retraining Credit 17. .00

18. Waste Motor Oil Burning Equipment Credit 18. .00

19. Riparian Forest Buffer Protection For Waterways 19. .00

20. Virginia Coal And Production Incentive Tax Credit 20. .00

21. Enter the amount of credit assigned to another party 21. .00

22. Virginia Coal and Production Incentive Tax Credit available for use by owner (Subtract line 21 from line 20) 22. .00

23. Historic Rehabilitation Tax Credit 23. .00

24. Land Preservation Tax Credit 24. .00

25. Qualified Equity & Subordinated Debt Investments Tax Credit 25. .00

26. Total Nonrefundable credits (Total lines 1-19 and 22-25) 26. .00 •

Refundable Credits

27. 100% Coalfield Employment Enhancement and/or Virginia Coal Employment and Production

Incentive Tax Credits from Line 1 of your 2009 Schedule 306B 27. .00

28. Full credit: Enter amount from 2009 Form 306, Line 12a 28. .00

29. Full credit: Enter amount from your 2009 Form 306, line 12b 29. .00

30. 85% Credit: Enter amount from 2009 Form 306, line 13a 30. .00

31. 90% Credit: Enter amount from your 2009 Form 306, line 13b 31. .00

32. Total Coal Related Tax Credits allowable this year: Add Lines 28, 29, 30 and 31 32. .00

33. 2009 Coalfield Employment Enhancement Tax Credit earned to be used when completing your 2012 return

Enter amount from your 2009 Form 306, Line 11 33. .00

Notice

You have received this Schedule VK-1 because the above named Pass-Through Entity (PTE) earned income from Virginia sources and has passed

through to you a portion of that Virginia source income based on your ownership of the PTE. A copy of this schedule has been filed with the Virginia

Department of Taxation. Everyone who receives Virginia source income is subject to taxation by Virginia regardless of state of residency or domicile.

You may be required to file a Virginia tax return even though you may be a nonresident individual or a business domiciled outside of Virginia. To

determine if you are required to file a Virginia income tax return, consult your tax professional. Information and forms may be obtained at

www.tax.virginia.gov , or call the Virginia Department of Taxation at 804-367-8031 (individuals) or 804-367-8037 (businesses).

1043 09 VAVK12 TWF 36246 Copyright Forms (Software Only) - 2009 TW