Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Hathaway-Sycamores Child and Family Services
Employer identification number
95-1691005
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(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
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
9,206,897
38,988,803
42,344,276
42,261,797
44,844,264
177,646,037
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..
9,206,897
38,988,803
42,344,276
42,261,797
44,844,264
177,646,037
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.
177,646,037
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
9,206,897
38,988,803
42,344,276
42,261,797
44,844,264
177,646,037
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
231,734
269,976
90,214
38,896
41,264
672,084
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..
51,172
-403,286
8,995
41,518
81,425
-220,176
11
Total support (Add lines 7 through 10).
178,097,945
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
37,710,605
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
99.750 %
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
99.670 %
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(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.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(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.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Hathaway-Sycamores Child and Family Services
Employer identification number
95-1691005
Identifier
Return Reference
Explanation
Form 990, Part VI, Section A, line 2
The two officers are related through marriage. Larry Webb, member of the Board of Directors, is the insurance broker for the agency's property and casualty insurance.
Form 990, Part VI, Section B, line 11
The 990 is reviewed and approved by the Administration and Finance Committee prior to filing. The Administration and Finance Committee is a regular committee of the board, and has the power and authority of the board, as defined in the organizational by-laws, to act on behalf of the full board.
Form 990, Part VI, Section B, line 12c
PROCEDURES General Instructions 1. Affected Persons: Responsible to make full disclosure of any interest that might result in a conflict of interest to the Board prior to entry into a financial relationship which may bring a conflict into being. Full disclosure is to be made of any interest in or connection (as owner, officer, partner, etc. or monetarily) with any organization doing or seeking to transact business with Hathaway-Sycamores. This responsibility includes disclosure of a family member's known interest in or connection with such an organization. Disclosure will be made prior to entry into such relationship on a Conflict of Interest Form. 2. Additionally, in January of each year, each Affected Person will prepare an annual Conflict of Interest Statement affirming that he/she is not engaged in any conflict of interest activity, or disclosing any activity by the preparer which may result in or appear to be a possible conflict of interest. 3. Chief Financial Officer of Hathaway-Sycamores: Responsible for sending Conflict of Interest Statements to board members in January and assuring all forms are obtained. Any identified conflicts will be forwarded to the Administration and Finance Committee for review. CFO will maintain copies of all Conflict of Interest Statements for future reference. 4. Administration and Finance Committee: Responsible for reviewing any declarations where conflict of interest may exist, obtaining necessary clarification from the affected person, discuss statements with the affected person when action may be required, track for completion of remedial action if indicated and by the April Board Meeting make a summary report to the Board. On an on-going basis, the committee reviews any new potential conflicts reported throughout the year. 5. AVP, Human Resources: Responsible to inform all new Affected Persons who perform a staff role of this policy and obtain a Conflict of Interest Statement when their employment begins and annually thereafter. 6. Failure to abide by this policy may result in corrective action (such as a required change in the affected business relationship) and/or disciplinary action. Disciplinary action may include steps up to and including termination of the Affected Person from his/her relationship with Hathaway-Sycamores. 7. Concurrent reporting of conflict of interests is required. Waiting until the January annual disclosure process is not adequate. It is the responsibility of all Affected Persons to disclose a potential conflict of interest before the transaction is consummated. Concurrent disclosure requires a written explanation of the conflict of interest and why the relationship/agreement/etc. is still in the best interest of Hathaway-Sycamores.
Form 990, Part VI, Section B, line 15
The Board of Directors is responsible for setting and reviewing and compensation for the President/CEO and the CFO of the Organization. A Compensation Committee is appointed by the Chairman of the Board to review the President/CEO and CFO's compensation packages. The make-up of the Compensation Committee includes the Board Chairman, Vice Chairman and Immediate Past Chairman if still serving on the Board or another member of the Board as appointed by the Chairman. Recommendations made by this committee will be brought to the Board of Directors for approval. Independently commissioned salary comparisons as well as salary studies conducted by local, state and national associations are utilized in determining comparable salary data.
Form 990, Part VI, Section C, line 19
The organization makes its governing documents, conflict of interest policy, financial statements and Form 990 available to the public upon request.
Changes in Net Assets or Fund Balances:
Form 990, Part XI, line 5:
Net unrealized gains on investments: 595,742. Change in value of split-interest agreements 297,149. Total to Form 990, Part XI, Line 5: 892,891.
Form 990, Part XII, Line 2c:
There was no change in the process from the prior year.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.