Fort Walton Beach Medical Center Auxilary Inc — Form 990EZ, tax year 2010

View Fort Walton Beach Medical Center Auxilary Inc on 990iQ →

- TIN:

Form990-EZ
Click to see list of attachments

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)

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.

The organization may have to use a copy of this return to satisfy state reporting requirements.

OMB No. 1545-1150

2010

Open to Public
Inspection

For the 2010 calendar year, or tax year beginning 01-01-2010, and ending 12-31-2010

Check if applicable:

Address change

Name change

Initial return

Terminated

Amended return

Application pending

C Name of organization
Fort Walton Beach Medical Center Auxilary Inc

Number and street (or P. O. box, if mail is not delivered to street address)1000 Mar Walt Drive
Room/suite

City or town, state or country, and ZIP + 4 Fort Walton Beach, FL32547

D Employer identification number

23-7412360

E Telephone number

(850) 243-4416

F Group Exemption
Number. . bullet

G Accounting method: CashAccrualOther (specify) bullet

H Check bullet

required to attach Schedule B
(Form 990, 990-EZ, or 990-PF).I Website: bullet

N/AJ Tax-Exempt status(check only one)501(c)(3) Click to see attachment

501(c)( ) bullet

(insert no.) 4947(a)(1) or 527

K Check

if the organization is not a section 509(a)(3) supporting organization and its gross receipts are normally not more than $50,000. 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

$ 53,577


1	Contributions, gifts, grants, and similar amounts received . . . . . . . . .			1	0
2	Program service revenue including government fees and contracts . . . . . . .			2
3	Membership dues and assessments . . . . . . . . . . . . . .			3	641
4	Investment income . . . . . . . . . . . . . . . . . .			4	300
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 $ 4,714 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	1,430
d	Net income or (loss) from gaming and fundraising events (Add lines 6a and 6b and subtract line 6c)			6d	3,284
7a	Gross sales of inventory, less returns and allowances . . . .	7a	47,922
b	Less: cost of goods sold . . . . . . . . . .	7b	29,301
c	Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) . . . . . .			7c	18,621
8	Other revenue (describe in Schedule O) . . . . . . . . .			8
9	Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 . . . . . . . . .			9	22,846
10	Grants and similar amounts paid (list in Schedule O) . . . . . . . .			10	18,850
11	Benefits paid to or for members . . . . . . . . . . . . . . .			11
12	Salaries, other compensation, and employee benefits . . . . . . . . . . .			12
13	Professional fees and other payments to independent contractors . . . . . . . .			13	985
14	Occupancy, rent, utilities, and maintenance . . . . . . . . . . . . .			14	170
15	Printing, publications, postage, and shipping . . . . . . . . . . . .			15
16	Other expenses (describe in Schedule O) . . . . . . . . . .			16	2,415
17	Total expenses. Add lines 10 through 16 . . . . . . . . . . . .			17	22,420
18	Excess or (deficit) for the year (Subtract line 17 from line 9) . . . . . . . . .			18	426
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	69,773
20	Other changes in net assets or fund balances (explain in Schedule O) . . . . . . .			20	0
21	Net assets or fund balances at end of year. Combine lines 18 through 20 . . . . .			21	70,199

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 . . . . . . . . . .

65,662

65,388

23Land and buildings . . . . . . . . . . . . .

24Other assets (describe in Schedule O) . . . . . .

4,499

5,018

25Total assets . . . . . . . . . . . . . .

70,161

70,406

Total liabilities (describe in Schedule O) . . . . .

388

207

27Net assets or fund balances (line 27 of column (B) must agree with line 21) .

69,773

70,199

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? Health education
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 Various service activities to assist and educate patients Total volunteer hours during 2010: 12,105 (Grants $ 0) If this amount includes foreign grants, check here ...			28a	105
29 Grant scholarships open to any student applying for study in a health related field (Grants $ 0) If this amount includes foreign grants, check here ...			29a	12,500
30 Donations made to 501(c)3 organinizations in the community (Grants $ 0) If this amount includes foreign grants, check here ...			30a	6,350
31 Other program services (describe in Schedule O) . . . . . . . . . . . . (Grants $ ) If this amount includes foreign grants, check here...	31a
32 Total program service expenses (add lines 28a through 31a) . . . . . . . . .	32	18,955

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
Carol Koch 1000 Mar Walt Fort Walton Beach,FL32547	President20.00	0	0	0
Diane Suhre 1000 Mar Walt Fort Walton Beach,FL32547	1st Vice Pres2.00	0	0	0
Una Haeavner 1000 Mar Walt Fort Walton Beach,FL32547	2nd Vice Pres11.00	0	0	0
Diane Wade 1000 Mar Walt Fort Walton Beach,FL32547	Rec Secretary12.00	0	0	0
Sally Lee 1000 Mar Walt Fort Walton Beach,FL32547	Treasurer10.00	0	0	0
Ruth Huels 1000 Mar Walt Fort Walton Beach,FL32547	Treasurer/Gift Shop10.00	0	0	0
Bob Shea 1000 Mar Walt Fort Walton Beach,FL32547	Member at Large2.00	0	0	0
Rosemary Jenner 1000 Mar Walt Fort Walton Beach,FL32547	Member at Large4.00	0	0	0
Don Wade 1000 Mar Walt Fort Walton Beach,FL32547	Member at Large2.00	0	0	0
Pat Haas 1000 Mar Walt Fort Walton Beach,FL32547	Corr Secretary6.00	0	0	0

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 . . . .

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 ..............

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). ...................

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. ........................

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

If "Yes," has it filed a tax return on Form 990-T for this year? (see instructions) ........

35b

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 .............

37a

Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet

37a

Did the organization file Form 1120-POL for this year? ...............

37b

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

If “Yes,” complete Schedule L, Part II and enter the total amount involved .

38b

Section 501(c)(7) organizations. Enter:

Initiation fees and capital contributions included on line 9 ......

39a

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

0 ; section 4912 bullet

0 ; section 4955 bullet

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

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

Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization ................... bullet

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

41List the states with which a copy of this return is filed. bullet

42aThe organization's books are in care of bullet

Ruth Huels Telephone no. bullet

(850) 243-4416

Located at bullet

1001 Mar Walt Drive
Fort Walton Beach,FL ZIP + 4 bullet

32547

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

42b

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.

At any time during the calendar year, did the organization maintain an office outside of the U.S.?

42c

If “Yes,” enter the name of the foreign country: bullet

43 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041Check here ....... bullet

and enter the amount of tax-exempt interest received or accrued during the tax year . . . bullet

44a

Did the organization maintain any donor advised funds? If "Yes", Form 990 must be completed instead of

Yes

Form 990-EZ.. . . . . . . . . . . . . . . . . . . .

44a

Did the organization operate one or more hospital facilities during the year? If ‘Yes,’ Form 990 must be completed instead of Form990-EZ. . . . . . . . .

44b

Did the organization receive any payments for indoor tanning services during the year? . . . . . . .

44c

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

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. . . . . . . . .

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

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. . . . . . . . . .

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

Did the organization engage in lobbying activities? If "Yes," complete Schedule C, Part II . . . .

Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E . . .

49a

Did the organization make any transfers to an exempt non-charitable related organization? . . . .

49a

If "Yes," was the related organization a section 527 organization? . . . . . . . . .

49b

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

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

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 .................... Yes No

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

	Signature of officer	Date

	Type or print name and title

Paid Preparer's Use Only	Preparer's signature	Date	Check if self- employed	Preparer’s taxpayer identification number (See instructions)
	Firm’s name (or yours if self-employed), address, and ZIP + 4			EIN
				Phone no.

May the IRS discuss this return with the preparer shown above? See instructions ......... bullet

YesNo

Form 990-EZ (2010)

Additional Data

Software ID:
Software Version:

Form 990-EZ, Special Condition Description:

Special Condition Description

- TIN:

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.

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

Fort Walton Beach Medical Center Auxilary Inc

Employer identification number

23-7412360

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.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

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).

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 ..................................................

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

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)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

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).

Gross receipts from related activities, etc. (See instructions.) ..................

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.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

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 ...................... right arrow

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 ..................... right arrow

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 .................................................. right arrow

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 .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

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.") .	915	651	671	698	641	3,576
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......	79,205	60,369	52,765	57,523	52,637	302,499
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.	80,120	61,020	53,436	58,221	53,278	306,075
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.)						306,075

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...	80,120	61,020	53,436	58,221	53,278	306,075
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..	544	489	107	424	300	1,864
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.	544	489	107	424	300	1,864
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.)	45	225	347			617
13	Total support (Add lines 9, 10c, 11 and 12.).	80,709	61,734	53,890	58,645	53,578	308,556

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f)) .........

99.200 %

Public support percentage from 2009 Schedule A, Part III, line 15 ...............

99.190 %

Section D. Computation of Investment Income Percentage

Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f)) ......

0.600 %

Investment income percentage from 2009 Schedule A, Part III, line 17 .............

0.580 %

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 .......... right arrow

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 .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

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.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Fort Walton Beach Medical Center Auxilary Inc

Employer identification number

23-7412360

Identifier	Return Reference	Explanation
Other Investment Income	Form 990-EZ, Part I, Line 4	Interest income 300..
Income from Sales of Inventory	Form 990-EZ, Part I, Line 7	Income: Gross Receipts: 47,952. Returns and Allowances: 30. Less Cost of Goods Sold: 29,301. Gross Profit: 18,621. Cost of Goods Sold: Inventory at Beginning of Year: 0. Merchandise Purchased: 0. Cost of Labor: 0. Materials and Supplies: 0. Other Costs: 29,301. Inventory at End of Year: 0. Cost of Goods Sold: 29,301.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Scholarships. Grantee Name: Melinea Hinchey. Grantee Relationship: None. Date of Gift: 08/01/10. Amount Given: 2,500.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Donation to 501(c)3 organization. Grantee Name: Shelter House. Grantee Address: PO Box 220 Fort Walton Beach, FL 32549. Grantee Relationship: None. Date of Gift: 06/01/10. Amount Given: 2,250.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Donation to 501(c)3 organization. Grantee Name: Emerald Coast Children's Advocacy Center. Grantee Address: 401 McEwen Niceville, FL 32578. Grantee Relationship: None. Date of Gift: 06/01/10. Amount Given: 2,250.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Donation to 501(c)3 organization. Grantee Name: Covenant Hospice. Grantee Address: 5041 N. 12th Avenue Pensacola, FL 32504. Grantee Relationship: None. Date of Gift: 99/99/99. Amount Given: 100.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Donation to 501(c)3 organization. Grantee Name: Sharing and Caring. Grantee Address: 126 Beal Parkway Fort Walton Beach, FL 32548. Grantee Relationship: None. Date of Gift: 08/01/10. Amount Given: 1,000.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Donation to 501(c)3 organization. Grantee Name: Empty Stocking Fund. Grantee Relationship: None. Date of Gift: 12/01/10. Amount Given: 200.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Donation to 501(c)3 organization. Grantee Name: The American Heart Association. Grantee Address: 222 Hospital Drive Fort Walton Beach, FL 32547. Grantee Relationship: None. Date of Gift: 10/01/10. Amount Given: 500.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Donation to 501(c)3 organization. Grantee Name: Catholic Charities of NW Florida. Grantee Relationship: None. Amount Given: 50.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Scholarships. Grantee Name: Cheryl Coruo. Grantee Relationship: None. Date of Gift: 08/01/10. Amount Given: 1,500.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Scholarships. Grantee Name: Lila Dillon. Grantee Relationship: None. Date of Gift: 07/01/10. Amount Given: 2,500.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Scholarships. Grantee Name: Corey Launch. Grantee Relationship: None. Date of Gift: 07/01/10. Amount Given: 1,000.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Scholarships. Grantee Name: Nija Clark. Grantee Relationship: None. Date of Gift: 07/01/10. Amount Given: 1,500.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Scholarships. Grantee Name: Rebecca Hill. Grantee Relationship: None. Date of Gift: 07/01/10. Amount Given: 1,000.
Grants and Similar Amounts Paid	Form 990-EZ, Part I, Line 10	Activity Classification: Scholarships. Grantee Name: Jonathan Castro. Grantee Relationship: None. Date of Gift: 08/01/10. Amount Given: 2,500. Total included on Form 990-EZ, line 10: 18,850.
Occupancy, Rent, Utilities and Maintenence	Form 990-EZ, Part I, Line 14	Description: Depreciation. Amount: 170.
Other Expenses	Form 990-EZ, Part I, Line 16	Description: Office. Amount: 694. Description: Bank/credit card fees. Amount: 1,328. Description: Licenses. Amount: 30. Description: Dues and Fees. Amount: 105. Description: Special Projects. Amount: 258. Total to Form 990-EZ, line 16: 2,415.
Other Assets	Form 990-EZ, Part II, Line 24	Description: Inventory. Beg. of Year Amount: 2,913. End of Year Amount: 3,602. Description: Other Depreciable Assets. Beg. of Year Amount: 1,586. End of Year Amount: 1,416.
Other Liabilities	Form 990-EZ, Part II, Line 26	Description: Sales tax payable. Beg. of Year Amount: 388. End of Year Amount: 207.

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:

- TIN:

TY 2010 TransferPrsnlBnftContractsDecl

Name:

Fort Walton Beach Medical Center Auxilary Inc

EIN: 23-7412360

Declaration:

The organization did not, during the year, receive any funds, directly,or indirectly, to pay premiums on a personal benefit contract.The organization, did not, during the year, pay any premiums, directly,or indirectly, on a personal benefit contract.