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.") . | 600 | 600 | ||||
| 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...... | 158,049 | 162,291 | 153,556 | 149,341 | 137,922 | 761,159 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | 0 | |||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | 0 | |||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | 0 | |||||
| 6 | Total. Add lines 1 through 5. | 158,049 | 162,291 | 154,156 | 149,341 | 137,922 | 761,759 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | 0 | |||||
| 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. | 0 | |||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public Support (Subtract line 7c from line 6.) | 761,759 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 158,049 | 162,291 | 154,156 | 149,341 | 137,922 | 761,759 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 9,516 | 12,362 | 12,828 | 7,967 | 6,291 | 48,964 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 9,516 | 12,362 | 12,828 | 7,967 | 6,291 | 48,964 |
| 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.). | 167,565 | 174,653 | 166,984 | 157,308 | 144,213 | 810,723 |




| Facts And Circumstances Test |
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| Explanation |
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| Software ID: | 11000144 |
| Software Version: | 2011v1.2 |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Form 990-EZ, Part II, Line 24.1 | Other Assets.1 | DEPOSITS - Beginning $2344 DEPOSITS - Ending $2344 |
| Form 990-EZ, Part II, Line 24.1003 | Other Assets.1003 | Machinery and Equipment - Beginning $0 Machinery and Equipment - Ending $111 |
| Form 990-EZ, Part II, Line 24.1002 | Other Assets.1002 | Furniture and Fixtures - Beginning $467 Furniture and Fixtures - Ending $725 |
| Form 990-EZ, Part I, Line 16.14 | Other Expenses.14 | CASH OVER/SHORT $-14 |
| Form 990-EZ, Part I, Line 16.13 | Other Expenses.13 | FEES & LICENSES $10 |
| Form 990-EZ, Part I, Line 16.11 | Other Expenses.11 | OFFICE EXPENSES $60 |
| Form 990-EZ, Part I, Line 16.10 | Other Expenses.10 | BOX RENTAL $71 |
| Form 990-EZ, Part I, Line 16.9 | Other Expenses.9 | GAS REIMB- VOLUNTEERS $240 |
| Form 990-EZ, Part I, Line 16.8 | Other Expenses.8 | BUSINESS MEALS ON-SITE $380 |
| Form 990-EZ, Part I, Line 16.7 | Other Expenses.7 | SMALL EQUIPMENT $400 |
| Form 990-EZ, Part I, Line 16.6 | Other Expenses.6 | SUPPLIES $530 |
| Form 990-EZ, Part I, Line 16.5 | Other Expenses.5 | TELEPHONE $757 |
| Form 990-EZ, Part I, Line 16.4 | Other Expenses.4 | BUSINESS MEALS OFF-SITE $1101 |
| Form 990-EZ, Part I, Line 16.3 | Other Expenses.3 | STORAGE $1356 |
| Form 990-EZ, Part I, Line 16.2 | Other Expenses.2 | GIFTS $1926 |
| Form 990-EZ, Part I, Line 16.1 | Other Expenses.1 | REPAIRS AND MAINTENANCE $2937 |
| Form 990-EZ, Part I, Line 16.1012 | Other Expenses.1012 | Insurance $2049 |
| Form 990-EZ, Part I, Line 16.1009 | Other Expenses.1009 | Depreciation $3397 |
| Form 990-EZ, Part I, Line 16.1001 | Other Expenses.1001 | Advertising and Promotion $239 |
| Form 990-EZ, Part I, Line 10.12 | Grants and Similar Amounts Paid In Excess of $5,000.12 | Class of Activity: NON-PROFIT PUBLIC CHARITY | Donee's Name: LOS ALAMOS RETIRED & SENIOR ORGANIZATION | Donee's Address: 1101 BATHTUB ROW LOS ALAMOS, NM 87544 | Cash Amount Given: $31000 |
| Form 990-EZ, Part I, Line 10.11 | Grants and Similar Amounts Paid In Excess of $5,000.11 | Class of Activity: NON-PROFIT PUBLIC CHARITY | Donee's Name: LOS ALAMOS GROUP HOME INC | Donee's Address: 595 LOS PUEBLOS LOS ALAMOS, NM 87544 | Cash Amount Given: $30000 |
| Form 990-EZ, Part I, Line 10.9 | Grants and Similar Amounts Paid In Excess of $5,000.9 | Class of Activity: NON-PROFIT PUBLIC CHARITY | Donee's Name: SALVATION ARMY | Donee's Address: 2707 E VAN BUREN PHOENIX, AZ 85008 | Cash Amount Given: $12000 |
| Form 990-EZ, Part I, Line 10.7 | Grants and Similar Amounts Paid In Excess of $5,000.7 | Class of Activity: NON-PROFIT PUBLIC CHARITY | Donee's Name: LA CARES | Donee's Address: 522 CANYON RD LOS ALAMOS, NM 87544 | Cash Amount Given: $12000 |
| Form 990-EZ, Part I, Line 10.6 | Grants and Similar Amounts Paid In Excess of $5,000.6 | Class of Activity: NON-PROFIT PUBLIC CHARITY | Donee's Name: FAMILY STRENGTHS NETWORK | Donee's Address: 1900 DIAMOND DR LOS ALAMOS, NM 87544 | Cash Amount Given: $6000 |
| Form 990-EZ, Part I, Line 10.4 | Grants and Similar Amounts Paid In Excess of $5,000.4 | Class of Activity: RELIGIOUS ORGANIZATION | Donee's Name: HIGH SCHOOL LUNCH-TRINITY EPISCOPAL | Donee's Address: 3900 TRINITY DR LOS ALAMOS, NM 87544 | Cash Amount Given: $12000 |
| Form 990-EZ, Part I, Line 10.3 | Grants and Similar Amounts Paid In Excess of $5,000.3 | Class of Activity: NON-PROFIT EDUCATIONAL | Donee's Name: SAGE COTTAGE SCHOOL | Donee's Address: 142 MEADOW LANE LOS ALAMOS, NM 87544 | Cash Amount Given: $24000 |
| Form 990-EZ, Part I, Line 10.1 | Grants and Similar Amounts Paid In Excess of $5,000.1 | Class of Activity: GROUP HOME SUPPORT | Donee's Name: CASA MESITA GROUP HOME | Donee's Address: 4007 SYCAMORE LOS ALAMOS, NM 87544 | Cash Amount Given: $14000 |
| Software ID: | 11000144 |
| Software Version: | 2011v1.2 |