2021 Federal Statements Page 1 Premium, Inc. 11-1111120 Statement 1 Form 1120S, Line 19 Other Deductions Other Deductions Statement 2 Form 1120S, Schedule K, Line 12a Charitable Contributions Cash Contributions - 60% Limitation Statement 3 Form 1120S, Schedule K, Line 17d Other Items and Amounts Gross Receipts for Section 448(c) Statement 4 Form 1120S, Schedule L, Line 6 Other Current Assets Statement A-QBI Pass-through Entity Reporting Complete Statement A-QBI Pass-through Entity Reporting (Schedule K-1, Box 17, Code V) for Premium, Inc. Statement A-QBI Pass-through Entity Reporting (Schedule K-1, Box 17, Code V) Shareholder 1 If required, round amounts to the nearest dollar. Note: Box 12: Code A is is to report cash charitable contributions. Box 16: Code C is used to report nondeductible expenses, and Code D is used to report distributions not reported on Form 1099-DIV. Box 17: Code A is used to report Investment income, Code AC is used to report gross receipts for Section 448(c) purposes. Box 17: Code V is used to report information required for the QBI deduction. You are not required to provide a statement of the QBI items. Complete Statement A-QBI Pass-through Entity Reporting (Schedule K-1, Box 17, Code V) for Premium, Ir Statement A-OBI Pass-throuah Fntitv Renortina (Schedule K-1. Box 17. Code V) For Paperwork Reduction Act Notice, see the Instructions for Form 1120-s. www.irs.gov/Form1120S Schedule K-1 (Form 1120-S) 2021 Shareholder 1 If required, round amounts to the nearest dollar. Note: Box 12: Code A is is to report cash charitable contributions. Box 16: Code C is used to report nondeductible expenses, and Code D is used to report distributions not reported on Form 1099-DIV. Box 17: Code A is used to report Investment income, Code AC is used to report gross receipts for Section 448(c) purposes. Box 17: Code V is used to report information required for the QBI deduction. You are not required to provide a statement of the QBI items. Required: Prepare Premium's Form 1120S, Additional Information - Continuation Statement, and Schedule K-1s for John Parsons and George Smith, 5607 20th Street, Cut and Shoot, TX 77303. - If an amount box does not require an entry or the answer is zero, enter "0". - Enter all amounts as positive numbers, unless otherwise instructed. - If required, round amounts to the nearest dollar. - Make realistic assumptions about any missing data. Note: This problem is for the 2021 tax year. John Parsons (123-45-6781) and George Smith (123-45-6782) are 70\% and 30\% owners, respectively, of Premium, Inc. (11-111120), candy company located at 1005 16th Street, Cut and Shoot, TX 77303. Premium's S election was made on January 15, 2012, its date of incorporation. The following information was taken from the company's 2021 income statement