Civic Intelligence

Independence House

EIN 95-4016617 • 501(c)3 • Los Angeles, CA

Pub. 78 Eligible

Profile

To provide an environment for learning disabled young adults to acquire the skills necessary to function independently.

3640 S Sepulveda BlvdLos Angeles, CA 90034

n/A

Siviq Scores

Precomputed percentiles relative to similar nonprofits. These scores are descriptive rather than judgmental.

Liabilities / Assets

32nd percentile

0.01x

Higher debt load relative to assets than 32% of similar nonprofits.

501(c)3 • $1M-$5M nonprofits • Source year 2023

Liabilities / Revenue

29th percentile

0.01x

Higher debt load relative to revenue than 29% of similar nonprofits.

501(c)3 • $1M-$5M nonprofits • Source year 2023

Net Margin

79th percentile

28%

Higher net margin than 79% of similar nonprofits.

501(c)3 • $1M-$5M nonprofits • Source year 2023

Top Officer Pay

Score unavailable

No value available

No filing with officer rows is available for this organization yet.

Asset Growth

87th percentile

38%

Faster asset growth than 87% of similar nonprofits.

501(c)3 • $1M-$5M nonprofits • Annualized from 2022 to 2023

Revenue Growth

60th percentile

13%

Faster revenue growth than 60% of similar nonprofits.

501(c)3 • $1M-$5M nonprofits • Annualized from 2022 to 2023

Balance Sheet
Liabilities / Assets32nd percentile

Assets

Up

$1,458,479

Up $190,907 (+15%) from 2024

Liabilities

Up

$13,784

Up $5,476 (+66%) from 2024

Net Assets

Up

$1,444,695

Up $185,431 (+15%) from 2024

Operations
Liabilities / Revenue29th percentileNet Margin79th percentile

Revenue

Down

$960,133

Down $39,619 (-4.0%) from 2024

Expenses

Up

$774,702

Up $35,169 (+4.8%) from 2024

Net Income

Down

$185,431

Down $74,788 (-29%) from 2024

Trend Graphs

Balance Sheet Trend

Asset Growth87th percentile

Grouped bars show assets, liabilities, and net assets across loaded filings.

$1.5M$1.0M$500K$0Assets 2010: $589,112Liabilities 2010: $0Net Assets 2010: $589,1122010Assets 2011: $591,056Liabilities 2011: $0Net Assets 2011: $591,0562011Assets 2012: $480,698Liabilities 2012: $0Net Assets 2012: $480,6982012Assets 2013: $395,521Liabilities 2013: $0Net Assets 2013: $395,5212013Assets 2014: $330,583Liabilities 2014: $0Net Assets 2014: $330,5832014Assets 2015: $257,014Liabilities 2015: $0Net Assets 2015: $257,0142015Assets 2016: $239,946Liabilities 2016: $0Net Assets 2016: $239,9462016Assets 2017: $187,463Liabilities 2017: $0Net Assets 2017: $187,4632017Assets 2018: $160,939Liabilities 2018: $0Net Assets 2018: $160,9392018Assets 2019: $213,712Liabilities 2019: $35,410Net Assets 2019: $178,3022019Assets 2020: $284,990Liabilities 2020: $10,397Net Assets 2020: $274,5932020Assets 2021: $531,801Liabilities 2021: $43,736Net Assets 2021: $488,0652021Assets 2022: $732,570Liabilities 2022: $6,889Net Assets 2022: $725,6812022Assets 2023: $1,009,550Liabilities 2023: $10,505Net Assets 2023: $999,0452023Assets 2024: $1,267,572Liabilities 2024: $8,308Net Assets 2024: $1,259,2642024Assets 2025: $1,458,479Liabilities 2025: $13,784Net Assets 2025: $1,444,6952025

Highlighted filing

2025

Assets$1,458,479
Liabilities$13,784
Net Assets$1,444,695
Open 2025 Filing

Operations Trend

Revenue Growth60th percentile

Revenue, expenses, and net income by year, with the latest filing highlighted.

$1.0M$500K$0-$500KExpenses 2010: $813,4772010Revenue 2011: $842,246Expenses 2011: $840,302Net Income 2011: $1,9442011Expenses 2012: $829,5792012Revenue 2013: $755,899Expenses 2013: $841,076Net Income 2013: -$85,1772013Revenue 2014: $669,269Expenses 2014: $734,207Net Income 2014: -$64,9382014Revenue 2015: $673,158Expenses 2015: $746,727Net Income 2015: -$73,5692015Revenue 2016: $597,826Expenses 2016: $614,894Net Income 2016: -$17,0682016Revenue 2017: $562,265Expenses 2017: $614,748Net Income 2017: -$52,4832017Revenue 2018: $578,788Expenses 2018: $605,312Net Income 2018: -$26,5242018Revenue 2019: $691,525Expenses 2019: $674,162Net Income 2019: $17,3632019Revenue 2020: $686,339Expenses 2020: $590,048Net Income 2020: $96,2912020Revenue 2021: $785,790Expenses 2021: $572,318Net Income 2021: $213,4722021Revenue 2022: $873,746Expenses 2022: $636,130Net Income 2022: $237,6162022Revenue 2023: $986,711Expenses 2023: $713,347Net Income 2023: $273,3642023Revenue 2024: $999,752Expenses 2024: $739,533Net Income 2024: $260,2192024Revenue 2025: $960,133Expenses 2025: $774,702Net Income 2025: $185,4312025

Highlighted filing

2025

Revenue$960,133
Expenses$774,702
Net Income$185,431
Open 2025 Filing

Filings

Most recent year

2025 • Form 990Detailed filing. Detailed filing data is available for this year.

Open filing
Assets
$1,458,479
Liabilities
$13,784
Net assets
$1,444,695
Revenue
$960,133
Expenses
$774,702
Net income
$185,431
Balance SheetOperations
YearAssetsLiabilitiesNet AssetsRevenueExpensesNet Income
2025Detailed filing. Detailed filing data is available for this year.$1.46$0.01$1.44$0.96$0.77$0.19
2024Detailed filing. Detailed filing data is available for this year.$1.27$0.01$1.26$1.00$0.74$0.26
2023Detailed filing. Detailed filing data is available for this year.$1.01$0.01$1.00$0.99$0.71$0.27
2022Detailed filing. Detailed filing data is available for this year.$0.73$0.01$0.73$0.87$0.64$0.24
2021Detailed filing. Detailed filing data is available for this year.$0.53$0.04$0.49$0.79$0.57$0.21
2020Detailed filing. Detailed filing data is available for this year.$0.28$0.01$0.27$0.69$0.59$0.10
2019Detailed filing. Detailed filing data is available for this year.$0.21$0.04$0.18$0.69$0.67$0.02
2018Detailed filing. Detailed filing data is available for this year.$0.16$0.00$0.16$0.58$0.61$0.03
2017Detailed filing. Detailed filing data is available for this year.$0.19$0.00$0.19$0.56$0.61$0.05
2016Detailed filing. Detailed filing data is available for this year.$0.24$0.00$0.24$0.60$0.61$0.02
2015Detailed filing. Detailed filing data is available for this year.$0.26$0.00$0.26$0.67$0.75$0.07
2014Detailed filing. Detailed filing data is available for this year.$0.33$0.00$0.33$0.67$0.73$0.06
2013Detailed filing. Detailed filing data is available for this year.$0.40$0.00$0.40$0.76$0.84$0.09
2012Facts available. Structured filing facts are available, but richer extracted sections are limited.$0.48$0.00$0.48$0.83
2011Summary only. Only limited summary data is available for this year.$0.59$0.00$0.59$0.84$0.84$0.00
2010Facts available. Structured filing facts are available, but richer extracted sections are limited.$0.59$0.00$0.59$0.81
Latest Filing Detail
Jump To
Filing Snapshot
Filing Period
Jan 1, 2025 to Dec 31, 2025
Signed
Apr 20, 2026
Return Version
2025v4.1
Gross Receipts
$960,133
Mission and Program Overview

Mission

To provide an environment for learning disabled young adults to acquire the skills necessary to function independently.

Balance Sheet Detail
LineBeginningEndChange
Assets
Rtn Earn Endowment Incm Other Fnds$1,259,264$1,444,695▲ $185,431
Savings and Temporary Cash Investments$950,576$882,252▼ $68,324
Cash and Non-Interest-Bearing Accounts$297,739$557,439▲ $259,700
Prepaid Expenses and Deferred Charges$13,333$12,991▼ $342
Land, Buildings, and Equipment, Net$3,429$3,302▼ $127
Total Assets$1,267,572$1,458,479▲ $190,907
Other Assets Total$2,495$2,495→ $0
Liabilities
Deferred Revenue$5,728$8,027▲ $2,299
Unsecured Notes Loans Payable$2,580$5,757▲ $3,177
Total Liabilities$8,308$13,784▲ $5,476
Net Assets / Fund Balance
Total Net Assets Fund Balance$1,259,264$1,444,695▲ $185,431
Total Liabilities and Net Assets / Fund Balance$1,267,572$1,458,479▲ $190,907

Asset Categories

AssetBook ValueDepreciationBasis
Other Land Buildings$0$25,983$25,983
Equipment$0$19,758$19,758
Leasehold Improvements$3,302$196$3,498
Land$0--
Compensation and Service Providers
Top Officer PayScore unavailable

Employees

NameTitleFull / Part TimeBaseTotal
Miriam Gonzalez-coultasCEOFT$150,000$150,000

Board Members and Trustees

NameTitle
Michael J Klag MdCo-chair
Sandra D GordonCo-chair
Fay Ven Der Kar-levinsonBoard Member
Anahita Maficy Lovelace PhdDirector
Jill Greenspan EsqDirector
Melissa TuckerDirector
Ray CraemerDirector
Revenue and Support

Revenue Composition

Contributions and Grants
$206,850
Program Service Revenue
$700,720
Investment Income
$50,978
Other Revenue
$1,585
All Other Contributions
$206,850
Change in Net Assets
$185,431
Expenses and Functional Allocation

Major Expense Lines

Line ItemAmount
Other Expenses$473,032
Salaries, Compensation, and Employee Benefits$301,670
Grants and Similar Amounts Paid$0
Professional Fundraising Fees$0
Total Fundraising Expense$0

Functional Expense Allocation

Line ItemProgramManagementFundraisingTotal
Occupancy$198,943$66,314$0$265,257
Current Officers, Directors, Trustees, and Key Employees$75,000$75,000$0$150,000
Other Salaries and Wages$112,993$0$0$112,993
All Other Expenses$25,877$14,200$0$40,077
Fees for Services Accounting$0$23,719$0$23,719
Payroll Taxes$15,552$5,464$0$21,016
Fees for Services Other$18,300$0$0$18,300
Other Employee Benefits$13,776$3,885$0$17,661
Insurance$11,741$3,311$0$15,052
Office Expenses$0$9,223$0$9,223
Other Expenses$4,337$4,337$0$8,674
Advertising$408$520$0$928
Depreciation Depletion$127$0$0$127
Total Functional Expenses$568,729$205,973$0$774,702
Fundraising, Events, and Gaming
Fundraising activities
No
Gaming activities
No
Professional fundraiser used
No

Fundraising and Gaming Totals

Line ItemAmount
Professional Fundraising Fees$0
Political and Lobbying Activity
Political campaign activity
No
Lobbying activity
No
Subject to proxy tax
No
Governance and Compliance

Governance Checklist

Compiled or reviewed by an accountant
No
Annual disclosure for covered persons
No
Business relationship with 35% controlled entity
No
Business relationship with family members
No
Business relationship with organization members
No
Material changes to governing documents
No
Compensation from other sources disclosed
No
CEO compensation reviewed
No
Other officer compensation reviewed
No
Conflict-of-interest policy
Yes
Audited financial statements prepared
No
Key decisions subject to board approval
No
Management duties delegated
No
Filing and Contact Details

Filer

Filer Name
Independence House
EIN
95-4016617
Phone
3102027102
Address
3640 S SEPULVEDA BLVD, LOS ANGELES, CA 90034
Doing Business As
Independence Center

Signing Officer

Name
Miriam Gonzalez-coultas
Title
CEO
Phone
3102027102
Signed
2026-04-20
Discuss with paid preparer
Yes

Organization Details

Principal Officer
Miriam Gonzalez-coultas
Formed
1985
Legal Domicile
CA
Voting Board Members
8
Independent Board Members
0
Employees
10
Volunteers
0

Preparer

Firm
Tax & Accounting Offices Inc
Address
3701 Wilshire Blvd Ste 504, Los Angeles, CA 90010
Preparer
Mehrdad Fahim CPA
Phone
2133880060
Supplemental Narrative

Additional Explanations

Pt VI, Line 19

“If requested, the organization will furnish by mail or in person its governing documents, conflict of interest policy and/or financial statements.”

Pt VI, Line 11B

“The form 990 is reviewed by the board of directors which consists of attorneys and business men and women. Questions, if any are directed to the preparer.”

Raw XML AppendixShowing 400 of 407 raw XML fields

This appendix keeps the raw XML leaves available for debugging and edge-case review. The human report above is the primary experience.

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IRS990/OtherEmployeeBenefitsGrp/TotalAmt017661
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IRS990/OtherExpensesGrp/FundraisingAmt10
IRS990/OtherExpensesGrp/FundraisingAmt20
IRS990/OtherExpensesGrp/ManagementAndGeneralAmt00
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IRS990/OtherExpensesGrp/ManagementAndGeneralAmt24337
IRS990/OtherExpensesGrp/ProgramServicesAmt071541
IRS990/OtherExpensesGrp/ProgramServicesAmt120134
IRS990/OtherExpensesGrp/ProgramServicesAmt24337
IRS990/OtherExpensesGrp/TotalAmt071541
IRS990/OtherExpensesGrp/TotalAmt120134
IRS990/OtherExpensesGrp/TotalAmt28674
IRS990/OtherRevenueTotalAmt01585
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IRS990/OtherSalariesAndWagesGrp/ManagementAndGeneralAmt00
IRS990/OtherSalariesAndWagesGrp/ProgramServicesAmt0112993
IRS990/OtherSalariesAndWagesGrp/TotalAmt0112993
IRS990/PartialLiquidationInd0false
IRS990/PayPremiumsPrsnlBnftCntrctInd0false
IRS990/PayrollTaxesGrp/FundraisingAmt00
IRS990/PayrollTaxesGrp/ManagementAndGeneralAmt05464
IRS990/PayrollTaxesGrp/ProgramServicesAmt015552
IRS990/PayrollTaxesGrp/TotalAmt021016
IRS990/PoliticalCampaignActyInd0false
IRS990/PrepaidExpensesDefrdChargesGrp/BOYAmt013333
IRS990/PrepaidExpensesDefrdChargesGrp/EOYAmt012991
IRS990/PrincipalOfficerNm0MIRIAM GONZALEZ-COULTAS
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IRS990/ProgramServiceRevenueGrp/BusinessCd0900099
IRS990/ProgramServiceRevenueGrp/Desc0RESIDENCE PROGRAM
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IRS990/ProgramServiceRevenueGrp/TotalRevenueColumnAmt0700720
IRS990/ProgramServiceRevenueGrp/UnrelatedBusinessRevenueAmt00
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IRS990/PYContributionsGrantsAmt0139906
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IRS990/PYInvestmentIncomeAmt028043
IRS990/PYOtherExpensesAmt0423529
IRS990/PYProgramServiceRevenueAmt0831803
IRS990/PYRevenuesLessExpensesAmt0260219
IRS990/PYSalariesCompEmpBnftPaidAmt0316004
IRS990/PYTotalExpensesAmt0739533
IRS990/PYTotalRevenueAmt0999752
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IRS990/RcvFndsToPayPrsnlBnftCntrctInd0false
IRS990/ReconcilationRevenueExpnssAmt0185431
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IRS990/RelatedEntityInd0false
IRS990/RelatedOrganizationCtrlEntInd0false
IRS990/ReportInvestmentsOtherSecInd0false
IRS990/ReportLandBuildingEquipmentInd0true
IRS990/ReportOtherAssetsInd0false
IRS990/ReportOtherLiabilitiesInd0false
IRS990/ReportProgramRelatedInvstInd0false
IRS990/RevenueAmt0960133
IRS990/RtnEarnEndowmentIncmOthFndsGrp/BOYAmt01259264
IRS990/RtnEarnEndowmentIncmOthFndsGrp/EOYAmt01444695
IRS990/SavingsAndTempCashInvstGrp/BOYAmt0950576
IRS990/SavingsAndTempCashInvstGrp/EOYAmt0882252
IRS990ScheduleA/AmountsRcvdDsqlfyPersonGrp/TotalAmt00
IRS990ScheduleA/GiftsGrantsContrisRcvd509Grp/CurrentTaxYearAmt0206850
IRS990ScheduleA/GiftsGrantsContrisRcvd509Grp/CurrentTaxYearMinus1YearAmt0139906
IRS990ScheduleA/GiftsGrantsContrisRcvd509Grp/CurrentTaxYearMinus2YearsAmt0145725
IRS990ScheduleA/GiftsGrantsContrisRcvd509Grp/CurrentTaxYearMinus3YearsAmt0161651
IRS990ScheduleA/GiftsGrantsContrisRcvd509Grp/CurrentTaxYearMinus4YearsAmt0135440
IRS990ScheduleA/GiftsGrantsContrisRcvd509Grp/TotalAmt0789572
IRS990ScheduleA/GrossReceiptsAdmissionsGrp/CurrentTaxYearMinus4YearsAmt0598861
IRS990ScheduleA/GrossReceiptsAdmissionsGrp/TotalAmt0598861
IRS990ScheduleA/GrossReceiptsNonUnrltBusGrp/TotalAmt00
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IRS990ScheduleA/InvestmentIncomePYPct00.00000
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IRS990ScheduleA/PublicSupportCY170Pct00
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IRS990ScheduleA/PublicSupportPY509Pct01.00000
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IRS990ScheduleA/SubstAndDsqlfyPrsnsTotGrp/TotalAmt00
IRS990ScheduleA/SubstantialContributorsAmtGrp/TotalAmt00
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IRS990ScheduleA/Total509Grp/CurrentTaxYearMinus4YearsAmt0734301
IRS990ScheduleA/Total509Grp/TotalAmt01388433
IRS990ScheduleA/TotalSupportCalendarYearGrp/CurrentTaxYearAmt0206850
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IRS990ScheduleA/TotalSupportCalendarYearGrp/CurrentTaxYearMinus3YearsAmt0161651
IRS990ScheduleA/TotalSupportCalendarYearGrp/CurrentTaxYearMinus4YearsAmt0734301
IRS990ScheduleA/TotalSupportCalendarYearGrp/TotalAmt01388433
IRS990/ScheduleBRequiredInd0false
IRS990ScheduleD/EquipmentGrp/BookValueAmt00
IRS990ScheduleD/EquipmentGrp/DepreciationAmt019758
IRS990ScheduleD/EquipmentGrp/OtherCostOrOtherBasisAmt019758
IRS990ScheduleD/LandGrp/BookValueAmt00
IRS990ScheduleD/LandGrp/InvestmentCostOrOtherBasisAmt00
IRS990ScheduleD/LeaseholdImprovementsGrp/BookValueAmt03302
IRS990ScheduleD/LeaseholdImprovementsGrp/DepreciationAmt0196
IRS990ScheduleD/LeaseholdImprovementsGrp/OtherCostOrOtherBasisAmt03498
IRS990ScheduleD/OtherLandBuildingsGrp/BookValueAmt00
IRS990ScheduleD/OtherLandBuildingsGrp/DepreciationAmt025983
IRS990ScheduleD/OtherLandBuildingsGrp/OtherCostOrOtherBasisAmt025983
IRS990ScheduleD/TotalBookValueLandBuildingsAmt03302
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IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt0IF REQUESTED, THE ORGANIZATION WILL FURNISH BY MAIL OR IN PERSON ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND/OR FINANCIAL STATEMENTS.
IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt1THE FORM 990 IS REVIEWED BY THE BOARD OF DIRECTORS WHICH CONSISTS OF ATTORNEYS AND BUSINESS MEN AND WOMEN. QUESTIONS, IF ANY ARE DIRECTED TO THE PREPARER.
IRS990ScheduleO/SupplementalInformationDetail/FormAndLineReferenceDesc0Pt VI, Line 19
IRS990ScheduleO/SupplementalInformationDetail/FormAndLineReferenceDesc1Pt VI, Line 11b
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IRS990/StatesWhereCopyOfReturnIsFldCd0CA
IRS990/SubjectToProxyTaxInd0false
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IRS990/TerminateOperationsInd0false
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IRS990/TotalAssetsEOYAmt01458479
IRS990/TotalAssetsGrp/BOYAmt01267572
IRS990/TotalAssetsGrp/EOYAmt01458479
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IRS990/TotalContributionsAmt0206850
IRS990/TotalEmployeeCnt010
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IRS990/TotalFunctionalExpensesGrp/ManagementAndGeneralAmt0205973
IRS990/TotalFunctionalExpensesGrp/ProgramServicesAmt0568729
IRS990/TotalFunctionalExpensesGrp/TotalAmt0774702
IRS990/TotalGrossUBIAmt052563
IRS990/TotalLiabilitiesBOYAmt08308
IRS990/TotalLiabilitiesEOYAmt013784
IRS990/TotalLiabilitiesGrp/BOYAmt08308
IRS990/TotalLiabilitiesGrp/EOYAmt013784
IRS990/TotalNetAssetsFundBalanceGrp/BOYAmt01259264
IRS990/TotalNetAssetsFundBalanceGrp/EOYAmt01444695
IRS990/TotalOtherCompensationAmt00
IRS990/TotalProgramServiceExpensesAmt0568729
IRS990/TotalProgramServiceRevenueAmt0700720
IRS990/TotalReportableCompFromOrgAmt0150000
IRS990/TotalRevenueGrp/ExclusionAmt00
IRS990/TotalRevenueGrp/RelatedOrExemptFuncIncomeAmt0700720
IRS990/TotalRevenueGrp/TotalRevenueColumnAmt0960133
IRS990/TotalRevenueGrp/UnrelatedBusinessRevenueAmt052563
IRS990/TotalVolunteersCnt00
IRS990/TotLiabNetAssetsFundBalanceGrp/BOYAmt01267572
IRS990/TotLiabNetAssetsFundBalanceGrp/EOYAmt01458479
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IRS990/TypeOfOrganizationCorpInd0X
IRS990/UnrelatedBusIncmOverLimitInd0false
IRS990/UnsecuredNotesLoansPayableGrp/BOYAmt02580
IRS990/UnsecuredNotesLoansPayableGrp/EOYAmt05757
IRS990/USAddress/AddressLine1Txt03640 S SEPULVEDA BLVD 102
IRS990/USAddress/CityNm0LOS ANGELES
IRS990/USAddress/StateAbbreviationCd0CA
IRS990/USAddress/ZIPCd090034
IRS990/VotingMembersGoverningBodyCnt08
IRS990/VotingMembersIndependentCnt00
IRS990/WebsiteAddressTxt0N/A
IRS990/WhistleblowerPolicyInd0false
ReturnHeader/BuildTS02025-03-06 01:10:19Z
ReturnHeader/BusinessOfficerGrp/DiscussWithPaidPreparerInd0true
ReturnHeader/BusinessOfficerGrp/PersonNm0MIRIAM GONZALEZ-COULTAS
ReturnHeader/BusinessOfficerGrp/PersonTitleTxt0CEO
ReturnHeader/BusinessOfficerGrp/PhoneNum03102027102
ReturnHeader/BusinessOfficerGrp/SignatureDt02026-04-20
ReturnHeader/Filer/BusinessName/BusinessNameLine1Txt0INDEPENDENCE HOUSE
ReturnHeader/Filer/BusinessNameControlTxt0INDE
ReturnHeader/Filer/EIN0954016617
ReturnHeader/Filer/PhoneNum03102027102
ReturnHeader/Filer/USAddress/AddressLine1Txt03640 S SEPULVEDA BLVD
ReturnHeader/Filer/USAddress/CityNm0LOS ANGELES
ReturnHeader/Filer/USAddress/StateAbbreviationCd0CA
ReturnHeader/Filer/USAddress/ZIPCd090034
ReturnHeader/PreparerFirmGrp/PreparerFirmEIN0954582005
ReturnHeader/PreparerFirmGrp/PreparerFirmName/BusinessNameLine1Txt0Tax & Accounting Offices Inc
ReturnHeader/PreparerFirmGrp/PreparerUSAddress/AddressLine1Txt03701 Wilshire Blvd Ste 504
ReturnHeader/PreparerFirmGrp/PreparerUSAddress/CityNm0Los Angeles
ReturnHeader/PreparerFirmGrp/PreparerUSAddress/StateAbbreviationCd0CA
ReturnHeader/PreparerFirmGrp/PreparerUSAddress/ZIPCd090010
ReturnHeader/PreparerPersonGrp/PhoneNum02133880060

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