EFTA Document EFTA01280154

651112 Schedule K-1 (Form 1085) Fez Mier Sr year 20- 0. tax Department of the Treasury yea- bogInelng enairc Partner's Share of Income, Deductions, Credits, etc. ► See separate instructions. 'Marna! Reverwe Smite 2012 Information About the Partnership kientication number B Pedantic s came, address, city, stale) and ZIP code SV AMERICA HOLDINGS, LLC 42 HIGH TECH BLVD THOMASVILLE NC 27360 C IRS Center where partersiap filed return E -PILE D Ej Cneck if this is a publidy traded partnership (PIP) YAW Information About the Partner E Partner s id until ry number F Partner's name. address. LitY, state, and Z'P code BLUE CHIP CAPITAL, LLC 329 SEABREEZE AVENUE PALM BEACH, FL 33480 0 C General partner or I I.0 DU I imited partner or other LLC member-manager member Domestic oaths' LJ Foreign palter It What typo or entity s It is panne° PARTNERSHIP 12 'I m's partner is a retivemeM plan 0FWSEPA(eoginfetc.), check here I I J Partners share of groin, 'ass, and caprat Beginning Ending Profit 3.6001880% Loss 3.6001880% 3.6001880% 3.6001880% 3.9261080% caobi _ 3.9261080% K Partners share of Ratites at year en& lionrecourse Qualified norvecourse financing Recourse 283,514. $ 0 . L Palters copra/ account analysir Beginning capital account Caphal cunt-bared amigo Me year 500,000. Gwent year increase (decrease) 2,416. moorowa:s 8 d sbitutiens 12,6710 ending urging exam: 489,745. C Tax basis 0 BAAP 71 other (explain) IA Old the partner contribute property wit". a built-in gain o: loss? C Yee MIto If Yee. attach statement (see instructions) 0 Section 704(b) book 0'413-13 LHA For Paperwork Reduction Act Notice, Bee Instructions for Form 1 65. I I ril.P.C.1 C Amended K-1 OMB No. 1545.009. Part 111 Partner's Share of Current Year Income, Deductions, Credits, and Other Items 1 Ordinary business income (loss) 50,213. 2Newsmeweorcarcoome -6,518. 3 Other net rental income (Ices) 4 Tara-deed paymerts 6 Interest Income 2,576. 13, Cidinary &tends (lb OuallOed dtvklends 7 loyalties 8 Net short-term capital gain (loss) 9a lot long-farm capital gain (loss) 9b Colecttles(28%) gain (loss) tic Unrecaptured sec 1250 gain 10 Net section 1231 gam (loss) 130. 11 Other Income (loss) 16 Credits 16 Foreign tensactions 17 Albrnaltve mkt fax (AMT) Pans 1 477. 18 Tax-exempt income and nondeductble expenses * STMT 19 Distrindions 12,671. 20 Other intormagon A. 2,576. 12 Section 179 deduction 13 Other deductions A i 670. 14 Self-employment earrings(lass) 0. 'See attached statement for addition information. IHS.gov/forr 1065 22560411 137428 7386.003 CONFIDEITTlAtfiNGs• LLC Schedule K-1 (Fenn 1005) 2012 3 7386.001 SDNY_GM 00032878 EF1'A_00143491 EFTA01280154 SV AMERICA HOLDINGS, LLC SCHEDULE K-1 NONDEDUCTIBLE EXPENSES, BOX 18, CODE C DESCRIPTION EXCLUDED MEALS AND ENTERTAINMENT EXPENSES OFFICERS LIFE INSURANCE PARTNER FILING INSTRUCTIONS AMOUNT NONDEDUCTIBLE PORTION 537. 22. TOTAL TO SCHEDULE K-1, BOX 18, CODE C 559. SCHEDULE K-1 FOOTNOTES TO REDUCE THE PAPER DOCUMENTS WE CIRCULATE, WE OFFER THE FOLLOWING... INSTRUCTIONS IN ELECTRONIC FORMAT FOR SCHEDULE K-1 MAY BE FOUND AT: HTTP://WWW.SMITHLEONARDCPAS.COM/RESOURCES/TAX-CENTER/ CHOOSE TAX FORMS & PUBLICATIONS ENTER KEYWORDS "K-1 INSTRUCTIONS TAX FORM 1065." IF YOU WISH TO HAVE A PAPER COPY OF THIS DOCUMENT, PLEASE CALL US AT PARTNER NUMBER 3 22560411 137428 7386.003 CONP1OENITAt's , LLC 7386.001 SDNY_GM_00032879 EFTA _00 143492 EFTA01280155 3 Shhedub K-1 (Form IC65) 2012 This list Identifies the codes used os Schedule K-1 for all partners and provides summarized reporting information for partners who file Form 1040. For detailed reporting and Ming Information, see the separate Partners Inductions for Schedule K-1 and the instructions lor your Income tax return. 0 -day Nebel» ItMarne:deal peilmie where- the interns ~IS oceanor nonceee‘e end enter on yo-e tee" at bleed. Passive I,es Passive lime Nronoaerm lee Nerprosebe NCRne 2. Net coed real estate le-came00M 3. Other net ruts' ter* Bass) Nee ewe Na bee 4. Custenleed osyrrerds 6. kind income Se. Ortilniry cols/lards 0o. ()wired ehidende 7. I0/00 0. eel tobral-emn moral gin:Kee) ga het reng.:on Capital oor 30,11./ Ob. Colkactibles(3531)geln Mal 90. Inecoptal pellen 1203 pin 10. Nol ~en 123' gee (Ions) 11. Olt. ~rim 9oael Code A Over ~do iream. Boes) B hvolterry proem ene C Sec. 1228 comrade A MOP% CI el nip expleaden rare trawler. E Ceneeetenerdool F Oder inane Boa) 12. Sect cn *Wee "3. Dthe &tektite, A CS, eter. tons (5094; 9 tat ccer.bullone (32)18 C henna*, cenebflens(5O%) D hence, corrlabolone E CAPI2419•81 Orel:any IO • SCre otpr Won DO%) F Croke gain property (40%; • ContrIbuonn$1180%) II Invaelment hired napens I DeSacainns - tOyely domino Scomen ao»pj «pencils% K Dedreslortr partible (211 coal 1. Dedrámard • prone Coen) Al ~cute Wined reeler Nam ce Al Edo:rice/ eaártarce beetle O (Lonen( care bend in P %mad:both* period expanses o Commercial trhrto 'neon draueien ran rean real rota AS' R Peneona erd HA, S Rekroolatre moor. ertsart T Dorresbn peck/Olen aCtIritee Inkommecre • Oadirled veal n act:Oleo inane  Employe, / remt w.2 wages W Wier eedaalt Repel on See toe Fahwe'e If Schecitle E. line 28 °clam-i(,y Schedule E. lore 75, oourrn (1) Sr:dale E. We 28, Win 41 Sao tha Pfftreda nat.ohone Seheckde C. Ins 28, asre (g) See De Peter's Inegdalkee Schedue E. tine 28, coldme FM 1040.'008s Fr 1048 line Oa Font 1048 bra CO Schedu • E. We 4 Scledue D, lto tr :meeut D, Inn 12 20% Arts Gan Verkriwt. One 4 1.Se1ecke O Instrdcliort See Ile bebos--bore See he Palmeri nsuclbrs See the Parsee .hendct Cre See re 'etre( nelhctee Feyn 5781, Ilne 1 See rub. 635 Fern 1240, nee 210 'ore 91,2 Sen de Paine Irtriddlcre See Me Partnen leemachois See To Painedc ezbuctor a Form 4952. IIM 1 Scrondole E. line 12 See lhe nelnattone Schedule A. Ana 23 Sehmaule A. Ilya 28 Schedule A, Ono 1 ea Rem 1842 line 20 See the Plena(' Intruding* Ferro 244', Ira I' Sul the Peewee Inelnielone Bee porn $582 l- sttudlone See the 8delnet's Inetructbne See the rierMerio Irelrucbce• See rein 0033 menaces Ferm WA, are ab ram 808 ere 17 See Be Proem hetrutaill See angiomen( coy ngs Ore Nei. 1' yes here a secto^ '79 decbctei a any pa-innr.:evel nentglkne. eer te Pamela hathrzbunie Wire Campletrg Schedle • Nee tented (oes) tan Weer S1ePw1 • Ones twining er %bhp h‘cros C ter ncedrenn Income Is. Credits A Low.nocnte hodre cedit (BMW 4200 Irmo phh2CM bulldreds ▪ Lini.rno.noe Feasilg eredl Ceder> turn cre.2005 beano, C L ow-onoone - 0J*Ing all geode, 4208atom ~-2507 buildroz Co Low-emcee meting own (oral torn posi•22C7 odlcegs E Cue led tehabilarthan cape-she", read real orate)  0..ber Nb:real mire Cree'ne (I Qtr darts' credlos UrideralCuted cap tr toles trier I Neon°, rod odUlesieeelue hels etedt 2'1252 lle 19 Selector Sf, Settle, A cell Fles Peobeee IrotteeSone Soothe Pries Inethowns Sates Punnet newel one Faro 1040, am 71, chock box e See the +flees inauctionc 22560411 137428 7386.003 cad WOrk 0000.11r Ily nedt K De/abed &CMS Credit L Empowerment Ire and tower cunrunliy e-noio)'rerl creda /A Confl Ia Increasing -ever& *envelop N Orc11 for ~aye' rood ~KY inn Medan roam O Radon witalholdIng 8 Oho credits IC. Foreign Irsrescbmas A sdme of etrinty ce r./ S. pcososeien • (arob tiOirre err Yl err C arose bore ;arose al palm laved rev cro gem income rtatta a: painefaho his F C533 Ja E Goren' ~cry D Pasehoesteraxy Dec:echoes Wooers.: ard rippordened in parse INS G Morns mho». N 0Uhr DechrtIone aecceled sao aPPlelotalm P2213~ booms I ~eve draw/ J liontral ~WM K Cel. Other niermarlon • TOlMlbreVhline.pale Al fob/ lonrch mires aacrued N Raducreen in else eta ado Ia Mode O rtra Cad ng gees receipts P LerodertItrla ircome eon usen O Other loreol oareeziler• Page 2 Pepol cn 1 See Ito Fromerds Pelniddolc ) Ferril 1118 Pal I Ferm 1110, Pori I Ferm 1118. Ftr: Rem 1116, Par. berrel erelPn mam } reeve 1118 Plet) IT. AreinetA•mlnirni.wn tax W.1- ) rorne F Ctn. MAT IFaii• B Apusted 1,31,, a' Kea 5 Depletion Mee ran el & gee; ) 01, Los. A geothermal • due Income • ow, geothermal • drortictom 1 A Poe1.19805amecratcn r-cljatrant 18. Tax.exarror income alh1 nOnee0ACZIto ~refs A Tax exiveal Were« InCrrat B Obey texeurnol mere • Nonclod.criale exponocra 10. DLinbedlons A Gant and marmlatie ~riles B Dflutoon eerefl to »Man 737 C Oler prOpIrty 20. Othe Inkemetice A Ir ~Client ircarre El kneel-mint expel:am C ruit tax decl: Intormancr • Quarried remmillbskatexpendIttres (aM« hen rernal lea erM1o) E Base ce energy property F Reesormin cl low-harm teuelrE on« (tembr 42C:X58 G Romany • ot br, unarm housing aide room) 11 Readalre of rnartatmant I ~pin or etthr mina J LOolobaci, rimer • complete] keg ken contacts K Look-bedt Items' - Moamar Mmemaz nolod I. Dwocaone.i pwedy with «tree 1132 Mrdocrom Is ROC *ISO V' *Kb>, 179 delicban N Fohreet expense lc, rococo-Ms panner8 O &Own 4S7(y3) hternellin P Section 4.53.A:t4 tutelar O Bettie.' -200(]) &yeTarr R itemsl dlocable wocren expentAbdets I S EEG wired:do:1 met atmlle T Drooleir^ Irlornellor and gm U Arnen ;sect al ralcerdaare are  Unrelated busInctit LA man ircome W Preozetibulon We X5SO X Stnt3Dr ICXX)IrkrrI1 on • Cler ernmthn Far* 1110. Pal II Fan 1118 at II Ferro '118 Ine 12 teen 5071 Fenn 8ein Seethe Pallets ~morons See% Partners ~atone end Me ~am /Or Fenn 0251 Fyn 1040, moet Sett,r Python 1.1CLICtialgi Ce. the Parretti Ihstructlaw } Sim the Ported re Inatn.et Ems row 4052. rho 4o Form 4052. lino 5 Ferm 4135 Sim therOarletres Ineduelono 844 Mair Parretee Ineln.moons Earn 201', IntrE Fenn Hell, Ine a See Fan, 4255 See re Palner's nstnet ono see ran 8027 See Fcnn 8680 Rae 'I» Pe-tress tams ceNrinurrerAcc""' "c 3 7386.001 SDNY_GM_00032880 EFTA_00143493 EFTA01280156 IT-85 2012 Schedule IN K-1 Ste Form 49181 (R12 / 8-12) Indiana Department of Revenue Partner's Share of Indiana Adjusted (Noss Income, Deductions, Modifications, and Credits Tax Year Beginning 01 01 2012 end Ending 12 31 2012 Name of Partnership Federal Ident" umber LD Distributions -Provide INK-1 to each partner. Enclose IN .<-1 with IT-65 return. for intimation on the acceptable electrons data file format, vial the DepalmenEs website at wortin.gov/dor/3172.htm Pro rata amounts for lines 1 tnrobgh 26 of any nonresident partner must be mulipried by the Indiana apportionment percent, if applicable. from IT-65, Fne 4. Part I - Partner's Ideal flcadon Section (a) If Partner Is an Individual (please print clearly) Sociai Security Nanber: Last Name: Fket Name: al a2 a3 (o) If Partner Is an Ober Entity (abase orbit clearly) Federal Identification Number, Name: 51 BLUE CHIP CAPITAL LLC b2 (c) Partner's Stale of P.asIdenoe or Commercial Do,Meie cl FL (d) Ind9na lax WIthhed for Nonresident Partner (on WH-I8). _ d .00 (e} Partners Federal Pro Rata Percentage 3 . 6 0018 51. (0 Partners Tax as Computed on IT-65CCMP Colimn G .00 Part 2 - Distributive Share Amount (use apportioned figures for nonresident partners) 1. Ordinary business ineOme pons) 1280.00 2. Net rental •eel estate income (loss) -166.00 3. Other net rental income (loss) . 00 4. Guaranteed payments . 00 5. Interest income 66.00 6. Ordinary &viands .00 7. Royaities . 00 8. No: short-term capital gain (loss) . 00 9. Net long-term capital gain (loss) . 00 10. Net IIIC Section 1231 (AM (loss) 3.00 11. Other income (loss) . 00 12. ;RC Section 179 expense deduct:on . 00 13a. Portion of expenses related tc investment portfolio income, including Invostrnent Interest expense and ether (federal nornemized) deductions . 00 13b. Other f nformation from Eno 20 of federal K-1 related to investrnent Interest and expenses not listed elsewhere . 00 14. Total pro rata distribudoes (And lines 1 threugh 11; subtract eves 12,138, and I31) when applicalle.) 1183.00 Continued on next page ► 2602'1 12-05-12 1019 CONFIDENTIAL SDNY_GM_00032881 EFTA_00I 43494 EFTA01280157 IT-65 2012 Schedule IN K-1 Page 2 Part 3 - State Modification Add or s.:bract the following. Designate the distibutNe share amount of each modification to Indiana ad lustod gross income from line 2 on the front of Form IT-65. For .nonresidents, appty apportioned boxes. (Use a minus sign to denote negative amounts.) IS. State income axes deducted .00 16. Net bonus deprecation allOwance .00 17. Excess IRC Section 179 deduction . 00 :8. Interest on U.S. obligations . 00 19. AddbackMeducoon Coco: . 0 20. Addtack/Ced-ction Code: . 0 0 21. AddbacIODeductIon Code: .00 22. AgehaowDeduction Code: . 00 23. Addback/DsdoetiOn Code: . 0 0 24. Addback/Oedustion Code: . 00 25. AdobadvDeduction Code: . 00 26. Addbackteduction Code: . 0 0 27. Total distributve share of mocite=tions (add lines 15 through 26 and catty total to Column B on Schedule IT-S5COMP) . 0 0 Part 4 - Pro Rata Snare of Indiana Pass-through Tax Credits front Partnership 28. Enter the lame of to tax credit p(ogram, Its trten-digit ID code, and the dolor amount of the partner's distributive share to each alnwable credit Name of Credit: ID Code: a b c .00 .00 . 0 0 29. Total pass. two Jell croft (add linos ne, 281. and 28i) . 00 fte212 .!2a3-12 1019 I u hf liii 11111IIIII iligignm11111111 III! CONFIDENTIAL SDNY_GPL00032882 EFTA_00143495 EFTA01280158 NC K-1 (39) (D-403) 1C-11-12 2012 Partners Share of N.C. Income, Adjustments, and Credits North Carolma Depanmant of Revenue For talendar year 2012 or kcal year hoginring Partner': I dentifyl eg N u m bei Partners Name, Addresa, and ZIP Code BLUE CHIP CAPITAL LLC 329 SEABREEZE AVENUE PALM BEACH PL 33480 and onding Federal Em r I Partnership': Name, karen, and ZIP Code SV AMERICA HOLDINGS LLC 42 HIGH TECH BLVD THOMASVILLE NC 27360 Partnerebip's Pro Rata Share Item Antoon( Individuele Firma Form 0-400 Enter Amant on: All Partner* 1. Stan of partnerslib income (loss) 2. Additions tO ine0rhe (ÅSS) Addi0on for bonus de:reenden b. Ober additi0iS tO boem (ass) 3. Deductiens trom incomo (loss) a Deductie» fot bonus depreciation b. Other deductrons korn licome (loss) 4. Share of tax credIS 5. Share of tas withheld kom nonwage coma/ambo pakt tor persona services peetorned in N.C. 46401 1363 0 0 0 0 0 Page 2,1.Ine 35 Page 2, Line 36 Page 2, Line 44e Page 2, Line 49 Form D-40OI C Page 2,1 Ine 23 Nenresidente Only 6. Nonresident's share of N.C. taxable Interne (loss) 1. Nonresldont's share ot net tax pad by the mana0er of the partnership 35594 0 Page 2, Lila 51 Page 2, Line 24e AFFIRMATION ATTACHED 20020, V.MM CONFIDENTIAL SDNY_GM_OOO32883 EFTA_00 I 43496 EFTA01280159 NC-NPA (39) D-403 Nonresident Partner Affirmation North Carolina Department of Revenue 8.35 3 r Identifying Number Nonresident Partners Name, Address, and ZIP Code (BLUE CHIP CAPITAL LLC 329 SEABREEZE AVENUE PALM BEACH FL 33480 Date nonresident became partner In partnership 12/20/11 Partners Tax Year 01/01/12 12/31/12 beg.nning (MAI-DO-Yr) ending (MM-00-110) Partnership's Federal Employer ID Number Partnerships Name, Address, and ZIP Code SV AMERICA HOLDINGS, LLC 42 HIGH TECH BLVD THOMASVILLE NC 27360 n Partnership's Tax Year O1/Q1/12 12/31/12 bogiming (A4M-DD-Yr ending (MM-DD-Y» Type of Partner. C C Corooratior. S Corporation 50 Partnership Estate or Trust (RU in applicable circle) Note: This toon is not applicable to nomosidect partners who are incateilusts or grantor busts. I affirm that 1. The entity above is a nonresident partner in the pagraship shown above, and 2. I will timely tile the entity's applicable income tax return and pay the tax Imposed by North Carolina on the entity's share of the partnership income. Signature of Manager, Officer, or Fiduciary Date SE affirm that: the entity above is a nonresident partner In the partnership shown above. Signature of Managing Partner Date General Instructions Ina partnership having ore or more nomes'dent partners, the rr arming partner is responsible for reputing the share of the income and paying the tax due tor each nonresident miner. However, line nonresident partner is a corporation, par birdie, trust or estate, the managing partner Is not required to pay the tax an that partner's share of the partnership income provided the partner sirs this Nonresident Partner Affirmation affirming that the partner wit pay the tax wit its corporation, pa'tnership, trust or estate income tax return. Ws form must oe attached Ic the pytnershio return of the partnership shown ahem (Note: Ibis form is nor applicable to nonresident partners who are individuals or grantor tests.) Payment of the tax due by' he managing errs or aerie of corpoldors, Partnmsbara, trusts or estates tits are partners does not retove the partner from ulna a North Carona tax return. 2%a4 I 05-01.2 CONFIDENTIAL SDNY_GM_00032884 EFTA_00 I 43497 EFTA01280160