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? |
|||
|---|---|---|---|---|---|---|---|---|---|
| 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. | 0 | |||||
| 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.. | 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) 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.") . | 140,269 | 137,665 | 104,840 | 39,833 | 55,930 | 478,537 |
| 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.. | 23,384 | 24,881 | 43,843 | 51,829 | 40,760 | 184,697 |
| 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. | 163,653 | 162,546 | 148,683 | 91,662 | 96,690 | 663,234 |
| 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.) | 663,234 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 163,653 | 162,546 | 148,683 | 91,662 | 96,690 | 663,234 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 6,269 | 4,247 | 6,232 | 8,604 | 3,263 | 28,615 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 6,269 | 4,247 | 6,232 | 8,604 | 3,263 | 28,615 |
| 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.) | 68,308 | 80,297 | 92,836 | 106,142 | 347,583 | |
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | 1,039,432 | |||||




| Facts And Circumstances Test |
|---|
| OTHER INCOME PART III, LINE 12; DESCRIPTION: BINGO PROCEEDS; 2008: 11764.; 2009: 0.; 2010: 0.; 2011: 0.; DESCRIPTION: AMBULANCE BILLING; 2007: 68308.; 2008: 68533.; 2009: 92836.; 2010: 68774.; DESCRIPTION: ESTATE OF VIRGINIA VAUGHAN; 2010: 31279.; DESCRIPTION: REFUNDS; 2010: 587.; DESCRIPTION: TRANSFER FROM AUXILLARY; 2010: 2616.; DESCRIPTION: BANK ERROR; 2010: 144.; DESCRIPTION: MISC; 2010: 2742.; |
| Explanation |
|---|
| Software ID: | 11000175 |
| Software Version: |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Pt V, Line 3b | There is no unrelated income received | |
| Pt VI, Line 19 | Documents are available for viewing on the first Monday of each week. | |
| Pt VI, Line 6 | The organization has 33 volunteer members but no stockholders | |
| Pt VI, Line 7a | All members vote to elect officers and members | |
| Pt VI, Line 7b | Yes | |
| Pt VI, Line 11a | The tax return is available for any/all members to view | |
| Pt XI | Line 5. Checking account increased by $56,757, CD's & | |
| Special checking increased by $3,263 and Net Assets | ||
| increased by $299,024, for a total increase of $350,951 | ||
| to Net Assets and Fund Balance. | ||
| Form 990EZ, Part I, Line 16 | HEATING OIL GAS/DIESLE MISC TRASH PICKUP | |
| Form 990, Part IX, Line 24f | AMBULANCE SUPPLIES 7300. 7300. |
| Software ID: | 11000175 |
| Software Version: |