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. | 0 | |||||
| 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.. | 0 | |||||
| 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.") . | 662,173 | 801,456 | 690,660 | 704,688 | 653,392 | 3,512,369 |
| 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...... | 1,114,543 | 1,179,411 | 1,225,905 | 1,283,060 | 1,295,497 | 6,098,416 |
| 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. | 1,776,716 | 1,980,867 | 1,916,565 | 1,987,748 | 1,948,889 | 9,610,785 |
| 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.) | 9,610,785 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 1,776,716 | 1,980,867 | 1,916,565 | 1,987,748 | 1,948,889 | 9,610,785 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 775,005 | 70,225 | -1,582,275 | 602,312 | 831,422 | 696,689 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 775,005 | 70,225 | -1,582,275 | 602,312 | 831,422 | 696,689 |
| 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.) | 55,655 | 46,054 | 43,471 | 70,417 | 58,773 | 274,370 |
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | 10,581,844 | |||||




| Facts And Circumstances Test |
|---|
| OTHER INCOME PART III, LINE 12; DESCRIPTION: OTHER; 2006: 55655.; 2007: 46054.; 2008: 43471.; 2009: 70417.; 2010: 58773.; |
| Explanation |
|---|
| Software ID: | 10000104 |
| Software Version: |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Pt VI-A, Line 2 | The daughter of the Executive Director works at the facility | |
| Pt VI-A, Line 7a | Four of the Directors must be affiliated with The Old Ladies Home | |
| Pt VI-B, Line 11a | The Executive and Finance Committee members review the Form 990 | |
| Form 990EZ, Part I, Line 16 | ALL OTHER DIRECT CARE AND CARE RELATED | |
| Form 990EZ, Part II, Line 24 | ACCOUNTS RECEIVABLE - NET PREPAIDS INVESTMENTS | |
| Form 990EZ, Part II, Line 26 | ACCOUNTS PAYABLE & ACCRUED EXPENSES |
| Software ID: | 10000104 |
| Software Version: |