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.. | 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.") . | 85,128 | 105,799 | 324,288 | 298,095 | 436,784 | 1,250,094 |
| 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...... | 37,725 | 38,837 | 35,328 | 7,220 | 2,091 | 121,201 |
| 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. | 122,853 | 144,636 | 359,616 | 305,315 | 438,875 | 1,371,295 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | 1,994 | 2,550 | 365 | 4,909 | ||
| 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. | 24,116 | 20,000 | 44,116 | |||
| c | Add lines 7a and 7b.. | 24,116 | 20,000 | 1,994 | 2,550 | 365 | 49,025 |
| 8 | Public Support (Subtract line 7c from line 6.) | 1,322,270 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 122,853 | 144,636 | 359,616 | 305,315 | 438,875 | 1,371,295 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 4,297 | 4,504 | 1,607 | 1,024 | 11,432 | |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 4,297 | 4,504 | 1,607 | 1,024 | 11,432 | |
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | 1,536 | 10,797 | 12,333 | |||
| 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.). | 1,395,060 | |||||




| Facts And Circumstances Test |
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| IN KIND SERVICE CONTRIBUTIONS OF MEDICAL CARE AND SUPPORT.; |
| Explanation |
|---|
| Software ID: | 11000175 |
| Software Version: |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Pt VI, Line 12c | Each member of the Board of Directors is required to | |
| sign the Conflict of Interest Policy on an annual | ||
| basis and disclose annually any interest that could | ||
| give rise to an appearance of a conflict. | ||
| Pt VI, Line 19 | The Organization makes its governing documents, conflict | |
| of interest policy and financial statements available | ||
| to the general public upon request. | ||
| Pt XII, Line 2c | The Board of Directors acts as the committee to select | |
| the audit firm and to over see the completion of the | ||
| audit. | ||
| Pt VI, Line 11a | The Treasurer reviewed a draft of the Form 990 prior | |
| to its issuance. | ||
| Pt VI, Line 15 | The Board of Directors agreed to compensate Board members | |
| who provided services that were in excess of their | ||
| volunteer capacity at an average rate of $10 per hour. | ||
| Pt VII, Line 1g | Non cash contributions consist primarily of medical services | |
| rendered. |
| Software ID: | 11000175 |
| Software Version: |