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.") .... | 55,740 | 104,243 | 159,983 | |||
| 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.. | 55,740 | 104,243 | 159,983 | |||
| 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. | 159,983 | |||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 55,740 | 104,243 | 159,983 | |||
| 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). | 159,983 | |||||






| 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.) | 0 | |||||
| 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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| Software ID: | 11000175 |
| Software Version: |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Pt III, Line 2 | Yes,a new food program was started | |
| Pt III, Line 3 | No - organization did not cease or made changes in how it conducts programs | |
| Pt V, Line 3b | No unrelated income was received | |
| Pt V, Line 13a | Not licensed to issue any health plans | |
| Pt V, Line 14b | No funds received for indoor tanning | |
| Pt VI, Line 1a | 9 voting members | |
| Pt VI, Line 2 | No family or business relationship with any officer/director. | |
| Pt VI, Line 3 | No - organization never delegates management responsibilities. | |
| Pt VI, Line 4 | No - there were no changes to any governing documents. | |
| Pt VI, Line 5 | No assets have been diverted. | |
| Pt VI, Line 6 | No - there are no members or shareholders. | |
| Pt VI, Line 7a | No - there are no member/shareholder/direct that can elect others to governing board. | |
| Pt VI, Line 7b | No - governing body decisions are not subject to approval by others. | |
| Pt VI, Line 8a | Yes - minutes are taken at all meetings. | |
| Pt VI, Line 8b | Yes - minutes are taken at committee meetings. | |
| Pt VI, Line 10b | No local chapters or affiliates | |
| Pt VI, Line 11a | Yes - the governing body reviewed the 990 before filing. | |
| Pt VI, Line 12c | No - there is no conflict of interest policy. | |
| Pt VI, Line 15 | No - payroll is not excessive by any means. | |
| Pt VI, Line 18 | Copies of form 990 are available upon request. | |
| Pt VI, Line 19 | Governing documents are available upon request. | |
| Pt VII, Col (E) | No compensation to report | |
| Pt VII, Col (F) | No other compensation to report. | |
| Pt XI | Minor positive change in net assets | |
| Pt XII, Line 1 | No change in accounting methods. | |
| Pt XII, Line 2c | Yes - oversight committee is responsible for selecting independent accountant. | |
| Form 990, Part IX, Line 24f | WORKSHOPS 150. 150. CHARITABLE GIVING RENEWAL 400. 400. SUPPLIES 1984. 1984. UTILITIES 2303. 2303. | |
| Pt XII, Line 3b | No federal award has been attained. |
| Software ID: | 11000175 |
| Software Version: |