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.") .... | 41,600 | 5,000 | 65,000 | 111,600 | ||
| 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.. | 41,600 | 5,000 | 65,000 | 111,600 | ||
| 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).. | 62,768 | |||||
| 6 | Public Support. Subtract line 5 from line 4. | 48,832 | |||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 41,600 | 5,000 | 65,000 | 111,600 | ||
| 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). | 111,600 | |||||






| 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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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| 01. Form 990 governing body review (Part VI, line 11) | A soft copy of the 990 form is emailed to the governing body for review prior to submission to the Internal Revenue Service | |
| 02. Conflict of interest policy compliance (Part VI, line 12c) | To ensure the organization operates in a manner consistent with charitable purposes and does not engage in activities that could jeopardize its tax-exempt status periodic reviews shall be conducted The periodic reveiws shall at a minimum include the following subjects a Whether compensation arrangements and benefits are reasonable based on competent survey information and the result of arms length bargaining b Whether partnerships joint ventures and arrangements with management organizations conform to the organizations written policies are properly recorded reflect reasonable investment or payments for goods and services further charitable purposes and do not result in inurement inpermissable private benefit or in an excess benefit transaction Any interested person director principal officer or member of a committee with governing board delegated powers is covered by this policy After disclosure of the financial interest and all material facts and after any discussion with the interested person heshe shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon The remaining board committee members or a committee appointed by the chairperson shall decide if a conflict of interest exists | |
| 03. CEO, executive director, top management comp (Part VI, line 15a) | The Board of Directors approves compensation arrangements for its Executive Director that follows a conflict of interest policy Compensation is approved prior to payment and the terms of the agreement is documented This is the only top management position of the organization at this time and it isnt occupied | |
| 04. Other officer or key employee compensation (Part VI, line 15b | The Board of Directors approves compensation arrangements for its other officer and key employees that follows a conflict of interest policy Compensation is approved prior to payment and the terms of the agreement is documented The organization has no other officer or key employees positions filled | |
| 05. Governing documents, etc, available to public (Part VI, line 19) | The governing documents are made available to the public via request | |
| 06. Explanation of other changes in net assets or fund balances (Part XI, line 5) | Prior period adjustment was made to correctly reflect accounts payables |
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