Attach to Form 990 or Form 990-EZ.
See separate instructions.| (i) Name of supported organization |
(ii) EIN |
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) |
(iv) Is the organization in col. (i) listed in your governing document? |
(v) Did you notify the organization in col. (i) of your support? |
(vi) Is the organization in col. (i) organized in the U.S.? |
(vii) Amount of support? |
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|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | ||||
| Total | |||||||||
| Calendar year(or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3.. | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public Support. Subtract line 5 from line 4. | ||||||
| Calendar year(or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets.. | ||||||
| 11 | Total support (Add lines 7 through 10). | ||||||






| Calendar year(or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... | 5,846,141 | 6,193,993 | 6,939,625 | 4,202,937 | 300 | 23,182,996 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | 5,846,141 | 6,193,993 | 6,939,625 | 4,202,937 | 300 | 23,182,996 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public Support (Subtract line 7c from line 6.) | 23,182,996 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 5,846,141 | 6,193,993 | 6,939,625 | 4,202,937 | 300 | 23,182,996 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 42,731 | 15,221 | 6,968 | 48,466 | 268,819 | 382,205 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 42,731 | 15,221 | 6,968 | 48,466 | 268,819 | 382,205 |
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | ||||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | 5,888,872 | 6,209,214 | 6,946,593 | 4,251,403 | 269,119 | 23,565,201 |




| Facts And Circumstances Test |
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| Explanation |
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| DURING CALENDAR YEAR 2009, THE ORGANIZATION (COUNTRYSIDE RETIREMENT HOME) SOLD ALL OF THE ASSETS TO ANOTHER LONG TERM HEALTH CARE ORGINIZATION. FOR MOST OF 2009, THE ORGANIZATION OPERATED THE RETIREMENT HOME AND MAINTAINED OPERATIONS AS A TAX EXEMPT ORGANIZATION DURING 2009 UNTIL THE DATE OF THE SALE. CURRENTLY THE EXISTING ORGANIZATION (TITUS FELLOWSHIP OF SIOUX CITY, LTD) IS TAKING STEPS TO CHANGE ITS NON-PRIVATE FOUNDATION STATUS FROM THAT OF A PUBLIC CHARITY TO A SUPPORTING ORGANIZATION UNDER IRC 509(A)(3). |
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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| ANY SIGNIFICANT CHANGES IN CONDUCT FOR PROGRAM SERVICES | FORM 990, PAGE 2, PART III, LINE 3 | THE ORGANIZATION IS CURRENTLY TAKING STEPS TO BECOME A SUPPORTING ORGANIZATION (TYPE III) BY THE END OF CALENDAR YEAR 2011. THE ORGANIZATION PLANS TO REDEVELOP APPROPRIATE GOVERNANCE DOCUMENTS AND SUBMIT A APPLICATION TO THE SERVICE FOR CHANGE IN PUBLIC CHARITY STATUS. |
| ORGANIZATION'S PROCESS USED TO REVIEW FORM 990 | FORM 990, PAGE 6, PART VI, LINE 11B | COPY OF FROM 990 REVIEWED WITH BOARD OF DIRECTORS PRIOR TO FILING WITH IRS |
| ENFORCEMENT OF CONFLICTS POLICY | FORM 990, PAGE 6, PART VI, LINE 12C | ANNUAL REVIEW WITH ALL DIRECTORS, THE CONFLICT OF INTEREST POLICY AND INTERESTS THAT COULD GIVE RISE TO CONFLICTS |
| GOVERNING DOCUMENTS DISCLOSURE EXPLANATION | FORM 990, PAGE 6, PART VI, LINE 19 | TITUS FELLOWSHIP OF SIOUX CITY, LTD MAKES ALL OF THEIR GOVERNING DOCUMENTS, POLICIES, FINANCIAL STATEMENTS AND FORM 990 AVAILABLE TO THE GENERAL PUBLIC IN THE ADMINISTRATIVE OFFICE LOCATED AT 414 KINGSBERRY CT SERGEANT BLUFFS, IOWA 51054. |
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