Form990-EZ
Click to see attachment
Department of the Treasury
Internal Revenue Service
Short Form
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code
(except black lung benefit trust or private foundation)
bullet Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions).
All other organizations with gross receipts less than $200,000 and total assets less than $500,000 at the end of the year may use this form.
bulletThe organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-1150
2010
Open to Public
Inspection
A
For the 2010 calendar year, or tax year beginning 01-01-2010, and ending 12-31-2010
B
Check if applicable:
C Name of organization
POLK VISION INC
 
Number and street (or P. O. box, if mail is not delivered to street address)PO BOX 1506
  Room/suite
City or town, state or country, and ZIP + 4 HIGHLAND CITY, FL33846
D Employer identification number

20-0141870
E Telephone number

(863) 646-0439
F Group Exemption
Number. . bullet  
G Accounting method: Other (specify) bullet   H Check bulletI Website:bulletWWW.POLKVISION.COMJ Tax-Exempt status(check only one)—Click to see attachment(   ) bullet(insert no.) or
K Check bullet A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if the organization chooses to file a return, be sure to file a complete return.
L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts; If gross receipts are $200,000 or more, or if total assets (Part II, line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ.. . bullet $ 165,368
Part IRevenue, Expenses, and Changes in Net Assets or Fund Balances (See the instructions for Part I.) Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . .
VerticalRevenue 1 Contributions, gifts, grants, and similar amounts received . . . . . . . . . 1 113,394
2 Program service revenue including government fees and contracts . . . . . . . 2 50,000
3 Membership dues and assessments . . . . . . . . . . . . . . 3  
4 Investment income . . . . . . . . . . . . . . . . . . 4 1,974
5a Gross amount from sale of assets other than inventory . . . . 5a  
b Less: cost or other basis and sales expenses . . 5b  
c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) . . 5c  
6 Gaming and fundraising events
a Gross income from gaming (attach Schedule G if greater than $15,000) 6a  
b Gross income from fundraising events (not including $   of contributions from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceed $15,000) . . . . . . .
c Less: direct expenses from gaming and fundraising events . . . 6c  
d Net income or (loss) from gaming and fundraising events (Add lines 6a and 6b and subtract line 6c) 6d  
7a Gross sales of inventory, less returns and allowances . . . . 7a  
b Less: cost of goods sold . . . . . . . . . . 7b  
c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) . . . . . . 7c  
8 Other revenue (describe in Schedule O) . . . . . . . . . 8  
9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 . . . . . . . . . 9 165,368
VerticalExpenses 10 Grants and similar amounts paid (list in Schedule O) . . . . . . . . 10  
11 Benefits paid to or for members . . . . . . . . . . . . . . . 11  
12 Salaries, other compensation, and employee benefits . . . . . . . . . . . 12 122,957
13 Professional fees and other payments to independent contractors . . . . . . . . 13  
14 Occupancy, rent, utilities, and maintenance . . . . . . . . . . . . . 14 1,324
15 Printing, publications, postage, and shipping . . . . . . . . . . . . 15 5,172
16 Other expenses (describe in Schedule O) . . . . . . . . . . 16 57,275
17 Total expenses. Add lines 10 through 16 . . . . . . . . . . . . 17 186,728
VerticalNetAssets 18 Excess or (deficit) for the year (Subtract line 17 from line 9) . . . . . . . . . 18 -21,360
19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
end-of-year figure reported on prior year’s return) . . . . . . . . . . . 19 240,014
20 Other changes in net assets or fund balances (explain in Schedule O) . . . . . . . 20  
21 Net assets or fund balances at end of year. Combine lines 18 through 20 . . . . . Bullet 21 218,654
Part IIBalance Sheets Check if the organization used Schedule O to respond to any question in this Part II. . . . . . . . .

(See the instructions for Part II.)(A) Beginning of year(B) End of year
22Cash, savings, and investments . . . . . . . . . .
240,825
22
219,824
23Land and buildings . . . . . . . . . . . . .
 
23
 
24Other assets (describe in Schedule O) . . . . . .
2,400
24
2,243
25Total assets . . . . . . . . . . . . . .
243,225
25
222,067
26
Total liabilities (describe in Schedule O) . . . . .
3,211
26
3,413
27Net assets or fund balances (line 27 of column (B) must agree with line 21) .
240,014
27
218,654
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 10642I Form 990-EZ (2010)
Form 990-EZ (2010)
Page 2
Part IIIStatement of Program Service Accomplishments Check if the organization used Schedule O to respond to any question in this Part III . Expenses
(Required for section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional for others.)
What is the organization's primary exempt purpose? TO DEVELOP PLANS TO IMPROVE THE QUALITY OF LIFE, EDUCATION AND ECONOMIC DEVELOPMENT OF POLK COUNTY, FLORIDA. TO ASSIST, IN A CHARITABLE MANNER CONSISTENT WITH IRC SECTION 501(C)(3), IN CHARTING THE COURSE OF POLK COUNTY'S FUTURE.
Describe what was achieved in carrying out the organization's exempt purposes. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 DEVELOP PLANS TO IMPROVE THE QUALITY OF LIFE, EDUCATION AND ECONOMIC DEVELOPMENT OF POLK COUNTY, FLORIDA.
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet		 28a 167,860
29
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		29a
30
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		30a
31 Other program services (describe in Schedule O) . . . . . . . . . . . .
(Grants $   ) If this amount includes foreign grants, check here...MediumBullet		 31a
32 Total program service expenses (add lines 28a through 31a) . . . . . . . . . bullet 32 167,860
Part IVList of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated. (See the instructions for Part IV.) Check if the organization used Schedule O to respond to any question in this Part IV . . . . . . . .
(a) Name and address (b) Title and average
hours per week
devoted to position		 (c) Compensation
(If not paid,
enter -0-.) 		(d) Contributions to
employee benefit plans &
deferred compensation		 (e) Expense
account and
other allowances
GREG LITTLETONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 CHAIRMAN3.00 0    
EILEEN HOLDENClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 CHAIR ELECT3.00 0    
CINDY PRICEClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 PAST CHAIR3.00 0    
RICK GARCIAClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 TREASURER3.00 0    
COLLEEN BURTONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 EXECUTIVE DI40.00 75,705    
DR ALICE MURRAYClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 EDUCATION CH3.00 0    
JERRY MILLERClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 ECON DEV CHA3.00 0    
PAT STEEDClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 INFRASTRUCTU3.00 0    
DERIC FEACHERClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 GOVT CHAIR3.00 0    
KIM LONGClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 QUALITY OF L3.00 0    
NELSON KIRKLANDClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 CIVIC ENGAGE3.00 0    
PETER USINGERClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 BENCHMARK CH3.00 0    
MARSHA FAUXClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 M-A-L1.00 0    
CHARLES MCPHERSONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
DANIEL STETSONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 M-A-L1.00 0    
LEA ANN THOMASClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
TERRY WORTHINGTONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 M-A-L1.00 0    
MELONY BELLClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
SYLVIA BLACKMON ROBERTSClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
DEBRA BURDETTClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
STACY BUTTERFIELDClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
BETH CLARKClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
PAMELA CRAVENClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
TONY DELGADOClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 M-A-L1.00 0    
BOB ENGLISHClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
GOW FIELDSClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
MARSHALL GOODMANClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
JAY GRAY JRClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
STELLA HEATHClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
SANDI HOWARDClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
KAY HUTZELMANClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
GRADY JUDDClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
JOHN KAUTZClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
FRANK KENDRICKClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
JEFF KINCARTClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
MARGARET LOFTONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
RON MORROWClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
JOE O'LEARYClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
BONNIE PARKERClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
TOM PATTONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
CAROLE PHILIPSONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
ANGLELA PULIDOClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
MARTHA SANTIAGOClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
THERON STANGRYClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
JEFF TEBOClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
JOE TEDDERClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
MARLENE WAGNERClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
TOM DEARDORFFClick to see attachment
PO 1506
HIGHLAND CITY,FL33846
 M-A-L1.00 0    
ROB QUAMClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 M-A-L1.00 0    
ALLISON BEEMANClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
JACK BRANDONClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
BOBBY GREENClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
DANIEL HAIGHTClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
GARY HESTERClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
LEAH LAUDERDALEClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
SHERRI NICKELLClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
STEVEN SHEALEYClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
NAT WESTClick to see attachment
PO BOX 1506
HIGHLAND CITY,FL33846
 DIRECTOR1.00 0    
Form 990-EZ (2010)
Form 990-EZ (2010)
Page 3
Part VOther Information(Note the statement requirements in the instructions for Part V.)YesNo Check if the organization used Schedule O to respond to any question in this Part V . . . .
33
Did the organization engage in any activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ..............
33
 
No
34
Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the change on Schedule O (see instructions). ...................
34
 
No
35
If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but not reported on Form 990-T, explain in Schedule O why the organization did not report the income on Form 990-T. ........................
a
Did the organization have unrelated business gross income of $1,000 or more or was it a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements?
35a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year? (see instructions) ........
35b
 
 
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes,” complete applicable parts of Schedule N .............
36
 
No
37a
Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet
37a
 
b
Did the organization file Form 1120-POL for this year? ...............
37b
 
No
38a
Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?
38a
 
No
b
If “Yes,” complete Schedule L, Part II and enter the total amount involved .
38b
 
39
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on line 9 ......
39a
 
b
Gross receipts, included on line 9, for public use of club facilities ....
39b
 
40a
Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
section 4911 bullet   ; section 4912 bullet   ; section 4955 bullet  
b
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I. ....
40b
 
No
c
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 ..bullet  
d
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization ...................bullet  
e
All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T. .................
40e
 
No
41List the states with which a copy of this return is filed. bulletFL
42aThe organization's books are in care of bulletLARSONALLEN LLP Telephone no. bullet (863) 683-6783
Located at bulletPO BOX 1076
LAKELAND,FL ZIP + 4bullet33802
b
At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)?
Yes
No
42b
 
No
If “Yes,” enter the name of the foreign country: bullet  
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
c
At any time during the calendar year, did the organization maintain an office outside of the U.S.?
42c
 
No
If “Yes,” enter the name of the foreign country: bullet  
43.......bullet
and enter the amount of tax-exempt interest received or accrued during the tax year . . . bullet43
 
44a
Did the organization maintain any donor advised funds? If "Yes", Form 990 must be completed instead of
Yes
No
Form 990-EZ.. . . . . . . . . . . . . . . . . . . .
44a
 
No
b
Did the organization operate one or more hospital facilities during the year? If ‘Yes,’ Form 990 must be completed instead of Form990-EZ. . . . . . . . .
44b
 
No
c
Did the organization receive any payments for indoor tanning services during the year? . . . . . . .
44c
 
No
d
If 'Yes' to line 44c, has the organization filed a Form 720 to report these payments? If ‘No,’ provide an explanation in Schedule O. . . . . . . . .
44d
 
 
45
Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)? If ‘Yes,’ Form 990 and Schedule R must be completed instead of Form990-EZ. . . . . . . . .
45
 
No
45a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If ‘Yes,’ Form 990 and Schedule R must be completed instead of Form990-EZ. .
45a
 
No
46
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I. . . . . . . . . .
46
 
No
Form 990-EZ (2010)
Form 990-EZ (2010)
Page 4
Part VI
Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only. All section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b and 52. Check if the organization used Schedule O to respond to any question in this Part VI . . . . . . . .
Yes
No
47
Did the organization engage in lobbying activities? If "Yes," complete Schedule C, Part II . . . .
47
 
No
48
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E . . .
48
 
No
49a
Did the organization make any transfers to an exempt non-charitable related organization? . . . .
49a
 
No
b
If "Yes," was the related organization a section 527 organization? . . . . . . . . .
49b
 
 
50
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each employee paid more than $100,000 (b) Title and average
hours per week
devoted to position		 (c) Compensation
 (d) Contributions to
employee benefit plans &
deferred compensation		 (e) Expense
account and
other allowances
NONE
50(f)
Total number of other employees paid over $100,000 . . . . . . . . . . . . . bullet  

51
Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each independent contractor paid more than $100,000 (b) Type of service (c) Compensation
NONE
51(d)
Total number of other independent contractors each receiving over $100,000 . . . . . . . bullet  
52
Did the organization complete Schedule A? NOTE: All Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A ....................
Under penalties of perjury, I declare that I 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 officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(See instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
Form 990-EZ (2010)

Additional Data


Software ID:  
Software Version:  

Form 990-EZ, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
POLK VISION INC
 
Employer identification number

20-0141870
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(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?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
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.") .... 149,933 113,233 162,150 192,000 113,394 730,710
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.. 149,933 113,233 162,150 192,000 113,394 730,710
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.           730,710
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
7 Amounts from line 4.. 149,933 113,233 162,150 192,000 113,394 730,710
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 2,005 3,683 2,239 423 1,974 10,324
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).           741,034
12
12
197,616
13
Section C. Computation of Public Support Percentage
14
14
98.610 %
15
15
98.920 %
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
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......            
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.            
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.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
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.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
POLK VISION INC
 
Employer identification number

20-0141870
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule—
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
POLK VISION INC
  		Employer identification number

20-0141870
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
POLK VISION INC
  		Employer identification number

20-0141870
Part II
Noncash Property (see Instructions)
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
POLK VISION INC
  		Employer identification number

20-0141870
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
POLK VISION INC
 
Employer identification number

20-0141870
Identifier Return Reference Explanation
OTHER EXPENSES FORM 990-EZ, PART I, LINE 16 EXPENSES ADVERTISING 8,531 OFFICE SUPPLIES 9,840 TRAVEL 5,606 CONFERENCES / MEETINGS 24,020 INSURANCE 2,491 DUES & SUBSCRIPTIONS 245 ENTERTAINMENT & MEALS 587 CONTRACT LABOR 3,600 EQUIPMENT RENTAL 1,353 LICENSES 200 REPAIRS 802 TOTAL 57,275
OTHER ASSETS FORM 990-EZ, PART II, LINE 24 ACCOUNTS RECEIVABLE 0 650 FURNITURE & EQUIPMENT 5,457 5,974 LESS ACCUMULATED DEPRECIATION 3,164 4,488 DEPOSITS 107 107 TOTAL 2,400 2,243
OTHER LIABILITIES FORM 990-EZ, PART II, LINE 26 PAYROLL TAXES PAYABLE 3,211 3,253 UNITED WAY PAYABLE 0 160
PRIMARY EXEMPT PURPOSE FORM 990-EZ, PART III TO DEVELOP PLANS TO IMPROVE THE QUALITY OF LIFE, EDUCATION AND ECONOMIC DEVELOPMENT OF POLK COUNTY, FLORIDA. TO ASSIST, IN A CHARITABLE MANNER CONSISTENT WITH IRC SECTION 501(C)(3), IN CHARTING THE COURSE OF POLK COUNTY'S FUTURE.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  

TY 2010 CompensationExplanation
Name:
POLK VISION INC
EIN: 20-0141870
Person Name Explanation
GREG LITTLETON  
EILEEN HOLDEN  
CINDY PRICE  
RICK GARCIA  
COLLEEN BURTON  
DR ALICE MURRAY  
JERRY MILLER  
PAT STEED  
DERIC FEACHER  
KIM LONG  
NELSON KIRKLAND  
PETER USINGER  
MARSHA FAUX  
CHARLES MCPHERSON  
DANIEL STETSON  
LEA ANN THOMAS  
TERRY WORTHINGTON  
MELONY BELL  
SYLVIA BLACKMON ROBERTS  
DEBRA BURDETT  
STACY BUTTERFIELD  
BETH CLARK  
PAMELA CRAVEN  
TONY DELGADO  
BOB ENGLISH  
GOW FIELDS  
MARSHALL GOODMAN  
JAY GRAY JR  
STELLA HEATH  
SANDI HOWARD  
KAY HUTZELMAN  
GRADY JUDD  
JOHN KAUTZ  
FRANK KENDRICK  
JEFF KINCART  
MARGARET LOFTON  
RON MORROW  
JOE OLEARY  
BONNIE PARKER  
TOM PATTON  
CAROLE PHILIPSON  
ANGLELA PULIDO  
MARTHA SANTIAGO  
THERON STANGRY  
JEFF TEBO  
JOE TEDDER  
MARLENE WAGNER  
TOM DEARDORFF  
ROB QUAM  
ALLISON BEEMAN  
JACK BRANDON  
BOBBY GREEN  
DANIEL HAIGHT  
GARY HESTER  
LEAH LAUDERDALE  
SHERRI NICKELL  
STEVEN SHEALEY  
NAT WEST