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. | 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.. | ||||||
| 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.") . | 1,485 | 1,485 | 1,485 | 4,455 | ||
| 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...... | 273,347 | 282,699 | 291,389 | 847,435 | ||
| 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. | 274,832 | 284,184 | 292,874 | 851,890 | ||
| 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.) | 851,890 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 274,832 | 284,184 | 292,874 | 851,890 | ||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 3,304 | 1,214 | 738 | 5,256 | ||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 3,304 | 1,214 | 738 | 5,256 | ||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | 0 | |||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | 0 | |||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | 278,136 | 285,398 | 293,612 | 857,146 | ||




| 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 Part VI | 2 | Club manager/key employee Treasurer are husband wife |
| Form 990 Part VI | 6 | Organization has members who can join and pay 15 annual dues. |
| Form 990 Part VI | 7a | Members annually elect officers and directors to serve in their respective capacities. |
| Form 990 Part VI | 7b | Significant changes to Club operations or substantial contributions not previously given would require membership approval. |
| Form 990 Part VI | 19 | Governing documents annual financial statements along with IRS Form 990 would be available for public inspection at the Club office. |
| Form 990 Part VI | 11b | Form 990 will be available to the Board, membership, public after filed. Form 990 is reviewed by Treasurer CPA prior to filing. |
| Form 990 Part VI | 12c | Annual conflict of interest statement would be reviewed by all board members officers. Statement of non-conflict would be signed by each, presented to president of the Board for review filed. |
| Form 990 Part III Program Service Accomplishments | Line 4d Other Activities | Program Service Expenses 3,637, Grants and allocations 0, Revenue 0 Assist individual and family special needs as a result of medical emergencies or tragedies. 9 families assisted. |
| Form 990 Part III Program Service Accomplishments | Line 4d Other Activities | Program Service Expenses 288, Grants and allocations 0, Revenue 0 Childrens Christmas Party. Approximately 60 participants. |
| Form 990, Part III, Line 4d Program Service Expenses 3,637, Grants and allocations 0, Revenue 0 Assist individual and family special needs as a result of medical emergencies or tragedies. 9 families assisted. Form 990, Part III, Line 4d Program Service Expenses 288, Grants and allocations 0, Revenue 0 Childrens Christmas Party. Approximately 60 participants. Form 990 Part VI Section A Line 2 Club manager/key employee Treasurer are husband wife Form 990 Part VI Section A Line 6 Organization has members who can join and pay 15 annual dues. Form 990 Part VI Section A Line 7a Members annually elect officers and directors to serve in their respective capacities. Form 990 Part VI Section A Line 7b Significant changes to Club operations or substantial contributions not previously given would require membership approval. Form 990 Part VI Section C Line 19 Governing documents annual financial statements along with IRS Form 990 would be available for public inspection at the Club office. Form 990 Part VI Section B Line 11b Form 990 will be available to the Board, membership, public after filed. Form 990 is reviewed by Treasurer CPA prior to filing. Form 990 Part VI Section B Line 12c Annual conflict of interest statement would be reviewed by all board members officers. Statement of non-conflict would be signed by each, presented to president of the Board for review filed. |
| Software ID: | 11000218 |
| Software Version: | 2011.0.0 |