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.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
CENTRE LIFELINK EMERGENCY MEDICAL SERVICES INC
Employer identification number
23-7116953
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
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(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
Provide the following information about the supported organization(s).
(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.") ....
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.
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..
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).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
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.") .
444,815
497,028
414,487
688,204
338,300
2,382,834
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......
1,760,645
1,989,033
2,295,124
2,125,847
2,322,495
10,493,144
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.
2,205,460
2,486,061
2,709,611
2,814,051
2,660,795
12,875,978
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
0
c
Add lines 7a and 7b..
0
8
Public Support (Subtract line 7c from line 6.)
12,875,978
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...
2,205,460
2,486,061
2,709,611
2,814,051
2,660,795
12,875,978
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
25,187
40,066
28,249
27,383
41,136
162,021
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
25,187
40,066
28,249
27,383
41,136
162,021
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.)
53,631
16,367
25,724
11,214
65,078
172,014
13
Total support (Add lines 9, 10c, 11 and 12.).
2,284,278
2,542,494
2,763,584
2,852,648
2,767,009
13,210,013
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
97.470 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
1.230 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
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:
-
TIN:
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.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
CENTRE LIFELINK EMERGENCY MEDICAL SERVICES INC
Employer identification number
23-7116953
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 6
THE ORGANIZATION HAS FOUR CLASSES OF MEMBERS: (1) DIRECTORS, (2) ACTIVE VOLUNTEERS, (3) CREST MEMBERS, AND (4) LIFE MEMBERS. AN INDIVIDUAL MAY HOLD ONLY ONE CLASS OF VOTING MEMBERSHIP AT ANY ONE TIME. DIRECTOR AND ACTIVE VOLUNTEERS ARE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED FOR A VOTE TO THE MEMBERS OF THE ORGANIZATION. CREST AND LIFE MEMBERS ARE NOT ENTITLED TO VOTE ON ANY MATTERS SUBMITTED FOR A VOTE OF THE MEMBERS OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7A
AT THE ANNUAL MEETING, WHICH IS HELD WITHIN FOUR MONTHS OF THE FISCAL YEAR END, THE AGENDA INCLUDES THE ELECTION OF DIRECTORS (FROM THE NOMINEES), ANNUAL REPORTS, AND ANY MATTER WHICH REQUIRES THE VOTE OF THE MEMBERS OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7B
WHEN A NEW DIRECTOR IS APPOINTED BY THE BOARD TO FILL A VACANCY, THE NEW DIRECTOR SHALL SERVICE THE UNEXPIRED TERM OF THE PREDECESSOR IN OFFICE. AT THE ORGANIZATION'S NEXT ANNUAL MEETING FOLLOWING THE APPOINTMENT OF THE NEW DIRECTOR, THE APPOINTMENT OF THE NEW DIRECTOR SHALL BE SUBJECT TO A VOTE OF RATIFICATION BY THE MEMBERS ELIGIBLE TO VOTE. IF THE APPOINTMENT OF THE NEW DIRECTOR IS NOT APPROVED BY A MAJORITY OF VOTING MEMBERS PRESENT, THE SEAT SHALL ONCE MORE BECOME VACANT UNTIL SUCH TIME AS THE BOARD APPOINTS A SUCCESSOR.
FORM 990, PART VI, SECTION B, LINE 11
THE FORM 990 IS REVIEWED AND APPROVED BY THE ADMINISTRATIVE AFFAIRS COMMITTEE OF THE BOARD OF DIRECTORS PRIOR TO THE FILING WITH THE INTERNAL REVENUE SERVICE. THE FINAL FORM 990, AS FILED WITH THE INTERNAL REVENUE SERVICE, IS PROVIDED TO THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 12C
ALL MEMBERS OF THE BOARD OF DIRECTORS, ADMINISTRATIVE STAFF, AND MEMBERS WITH ADMINISTRATIVE RESPONSIBILITIES SHALL ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE. THE COMPLETED QUESTIONNAIRE SHALL BE SUBMITTED TO THE EXECUTIVE DIRECTOR FOR REVIEW. A REPORT CONCERNING ANY POTENTIAL CONFLICTS OF INTEREST SHALL BE PREPARED FOR SUBMISSION TO THE BOARD NO LATER THAN THE MARCH BOARD MEETING. ANY NEW EMPLOYEES WITH ADMINISTRATIVE RESPONSIBILITIES SHALL SUBMIT A COMPLETED QUESTIONNAIRE CONCURRENT WITH ASSUMPTION OF THEIR DUTIES. ANY POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY BOARD MEMBER SHALL BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD, BOTH THROUGH THE ANNUAL REPORTING PROCEDURE AND WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION. ANY BOARD MEMBER HAVING A POTENTIAL CONFLICT OF INTEREST ON ANY MATTER SHALL NOT VOTE ON THE MATTER, AND HE/SHE SHALL NOT BE COUNTED IN DETERMINING THE QUOROM FOR THE MEETING. THE MINUTES OF THE MEETING SHALL REFLECT THAT A DISCLOSURE WAS MADE AND THE ABSTENTION FROM VOTING. THIS SHALL NOT PREVENT A BOARD MEMBER FROM EITHER BRIEFLY STATING HIS/HER POSITION ON THE MATTER OR FROM ASWERING QUESTIONS OF OTHER BOARD MEMBERS SINCE HIS/HER KNOWLEDGE MAY BE OF ASSISTANCE. ANY PERSON SUBJECT TO CONFLICTS OF INTEREST DISCLOSURE WHOSE PERSONAL CIRCUMSTANCES CHANGE MATERIALLLY, SUCH THAT A NEW POTENTIAL CONFLICT OF INTEREST ARISES, SHALL REPORT THE NEW POTENTIAL CONFLICT TO THE PRESIDENT AT THE EARLIEST OPPORTUNITY. ALL CONFLICTS OF INTEREST QUESTIONNAIRES SHALL BE RETAINED BY THE EXECUTIVE DIRECTOR UNTIL THEY A SUPERCEDED BY A MORE CURRENT VERSION.
FORM 990, PART VI, SECTION C, LINE 19
WHEN A REQUEST IS RECEIVED FOR PUBLIC INSPECTION OF GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND/OR FINANCIAL STATEMENTS, MANAGEMENT WILL PRESENT THE FACTS AND CIRCUMSTANCES SPECIFIC TO THE INDIVIDUAL REQUEST TO THE BOARD OF DIRECTORS WHOM WILL DETERMINE IF THIS REQUEST WILL BE GRANTED.
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED GAINS ON INVESTMENTS: 84,759. RESTATEMENT TO REMOVE CERTAIN ASSETS - ORG DID NOT HAVE VARIANCE POWER OVER
PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR
FORM 990, PART XII, LINE 2C
PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.