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






| 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.") . | 57,671 | 57,671 | ||||
| 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.. | 132,550 | 132,550 | ||||
| 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. | 190,221 | 190,221 | ||||
| 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.) | 190,221 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 190,221 | 190,221 | ||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 129 | 129 | ||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 129 | 129 | ||||
| 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.). | 0 | 0 | 190,350 | 190,350 | ||




| Facts And Circumstances Test |
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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
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| 01. Members or stockholder classes and rights (Part VI, line 6) | If a member has a complaint about the business of one of the committees he or she may present a written description of the complaint to any of the members of the related committee In addition the complaint can be read at the next regular meeting At that point the necessary action will be taken by the related committee | |
| 02. Member election for additional members (Part VI, line 7a) | A new member is sponsored by an existing member The proposed membership is presented at the regular monthly meeting At that time any member can comment on the proposed new member After the discussion the new member is voted on by secret ballot A new member must be approved by 23 majority of members present The new member if accepted is presented at the next regular meeting | |
| 03. Governing body decisions (Part VI, line 7b) | There are 7 elected officers--Exalted Ruler Secretary Treasurer 3 Knights and Tiler The exalted ruler is in effect the president The secretary handles the paperwork The Treasurer takes care of all the money matters The Tiler is in effect the Sergeant at Arms There are 3 elected trustees who work with the Exalted Ruler and the 3 Knights to maintain the lodge property and facilities There 3 appointed officers--Chaplain Inner Guard Esquire The house commitee is made up of 13 members appointed by exalted ruler The house committee is responsible for operations of the club and restaurant There are other committees to handle the detail of smaller activities | |
| 04. Form 990 governing body review (Part VI, line 11) | DOCUMENTS AVAILABLE ONLY TO MEMBERS | |
| 05. Form 990 unavailable to public (Part VI, line 18) | documents available only to members | |
| 06. Governing documents, etc, available to public (Part VI, line 19) | Governing documents etc available to Public PV1-line 19 |
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