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) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | 96,620 | 103,796 | 339,325 | 183,379 | 182,641 | 905,761 |
| 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.. | 96,620 | 103,796 | 339,325 | 183,379 | 182,641 | 905,761 |
| 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. | 905,761 | |||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 96,620 | 103,796 | 339,325 | 183,379 | 182,641 | 905,761 |
| 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.. | 2,459 | 2,459 | ||||
| 11 | Total support (Add lines 7 through 10). | 908,220 | |||||






| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (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.) | ||||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (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.). | ||||||




| Facts And Circumstances Test |
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| Explanation |
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| Software ID: | 11000218 |
| Software Version: | 2011.0.0 |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Form 990-EZ, Part I, Line 16, Other Expenses Travel 621 Form 990-EZ, Part I, Line 16, Other Expenses Depreciation 1,356 Form 990-EZ, Part I, Line 16, Other Expenses Supplies 676 Form 990-EZ, Part I, Line 16, Other Expenses Telephone 3,476 Form 990-EZ, Part I, Line 16, Other Expenses Stipends 50 Form 990-EZ, Part I, Line 16, Other Expenses Staff Development Training 2,216 Form 990-EZ, Part I, Line 16, Other Expenses Accounting Financial Management 3,750 Form 990-EZ, Part I, Line 16, Other Expenses Audit 1,200 Form 990-EZ, Part I, Line 16, Other Expenses Small Furniture Equipment 435 Form 990-EZ, Part I, Line 16, Other Expenses Copier Lease Copier Maintenance 2,566 Form 990-EZ, Part I, Line 16, Other Expenses Software PC Support 187 Form 990-EZ, Part I, Line 16, Other Expenses Subscriptions Publications 200 Form 990-EZ, Part I, Line 16, Other Expenses Bank Fees 194 Form 990-EZ, Part I, Line 16, Other Expenses Meetings Expense 2,308 Form 990-EZ, Part I, Line 16, Other Expenses Other Office Administrative Expenses 260 Form 990-EZ, Part I, Line 16, Other Expenses Program Materials Supplies 283 Form 990-EZ, Part I, Line 16, Other Expenses Program Education Training 743 Form 990-EZ, Part I, Line 16, Other Expenses Program Consultants 6,400 Form 990-EZ, Part I, Line 16, Other Expenses Assistance to Individuals 300 Form 990-EZ, Part I, Line 16, Other Expenses Business Insurances 469 Form 990-EZ, Part I, Line 16, Other Expenses Community Outreach Awareness 480 Form 990-EZ, Part I, Line 16, Other Expenses Fundraising Event Expenses 996 Form 990-EZ, Part I, Line 16, Other Expenses Miscellaneous Expense 521 Form 990-EZ, Part II, Line 24, Other Assets Form 4562 Fixed Assets net book value Beginning of year 4,388, End of year 2,512 Form 990-EZ, Part II, Line 24, Other Assets Other Receivables Beginning of year 705, End of year 600 Form 990-EZ, Part II, Line 24, Other Assets Grant Receivables Beginning of year 0, End of year 41,901 Form 990-EZ, Part II, Line 26, Liabilities Accounts Payable Beginning of year 590, End of year 5,270 Form 990-EZ, Part II, Line 26, Liabilities Accrued Payroll Beginning of year 8,900, End of year 2,327 Form 990-EZ, Part II, Line 26, Liabilities Deferred Revenue - Connecticut Health Foundation Beginning of year 14,507, End of year 5,778 Form 990-EZ, Part II, Line 26, Liabilities Other Liabilities Beginning of year 0, End of year 25,000 |
| Software ID: | 11000218 |
| Software Version: | 2011.0.0 |