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? |
|||
|---|---|---|---|---|---|---|---|---|---|
| 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.") . | 0 | 0 | 0 | 0 | 43,250 | 43,250 |
| 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...... | 0 | 0 | 0 | 0 | 0 | 0 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | 0 | 0 | 0 | 0 | 0 | 0 |
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | 0 | 0 | 0 | 0 | 0 | 0 |
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | 0 | 0 | 0 | 0 | 0 | 0 |
| 6 | Total. Add lines 1 through 5. | 0 | 0 | 0 | 0 | 43,250 | 43,250 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | 0 | 0 | 0 | 0 | 0 | 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 | 0 | 0 | 0 | 0 | 0 |
| c | Add lines 7a and 7b.. | 0 | 0 | 0 | 0 | 0 | 0 |
| 8 | Public Support (Subtract line 7c from line 6.) | 43,250 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 0 | 0 | 0 | 0 | 43,250 | 43,250 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 0 | 0 | 0 | 0 | 0 | 0 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | 0 | 0 | 0 | 0 | 0 |
| c | Add lines 10a and 10b. | 0 | 0 | 0 | 0 | 0 | 0 |
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | 0 | 0 | 0 | 0 | 0 | 0 |
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | 0 | 0 | 0 | 0 | 0 | 0 |
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | 0 | 0 | 0 | 0 | 43,250 | 43,250 |




| Facts And Circumstances Test |
|---|
| Explanation |
|---|
| N/A |
| N/A |
| Software ID: | 11000129 |
| Software Version: | v1.00 |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| F990_P00_S00_L0B | Form 990, Header, Line B | A form 990N was filed. |
| F990_P03_S00_L02 | Form 990, Part III, Line 2 | The youth development and education department served over 107 youth during the year through a variety of in school, after school, and summer youth programs. The participants received academic support, career awareness training, work skills development and leadership training during the 2011 program year. The organization provided $16,000 in youth scholarships for the fiscal year ending in 12/31/2011. The youth development and education department provided physical activity and therapeutic recreation activities. A youth forum was provided to bring together concerned youth and adults to exchange information to further develop ideas for effective character building skills. In addition community service projects were developed from these ideas and will be implemented in the 2012 year. |
| F990_P06_S0B_L11b | Form 990, Part VI, Section B, Line 11b | The governing body reviewed form 990 at its second quarter meeting and a motion was passed to except the document as presented. |
| F990_P06_S0B_L12c | Form 990, Part VI, Section B, Line 12c | In an effort to monitor potential conflict of interest situations, members of the governing body are asked to disclose in writing any potential conflicts between personal interest and the interest of the organization at the quarterly meetings. In an effort to enforce this policy writen disclosure statements will be reviewed by a committee appointed by the President to determine if a conflict of interest exists. If it is determined that a conflict of interest exists, appropriate action will be taken to eliminate the conflict and safeguard the interest of the organization. |
| F990_P06_S0B_L15 | Form 990, Part VI, Section B, Line 15 | In an effort to determine compensation for the organizations officers or key employees the following process will be used: (1) a review by the executive committee of proposed salary/wage schedules, (2) use of comparable data for simularly qualified non-profits will be used to set salary/wage schedules, and (3) documentation of the boards consideration and approval of the compensation schedules will be maintained. |
| F990_P06_S0C_L19 | Form 990, Part VI, Section C, Line 19 | The organization will make its governing body documents, conflict of interest policy, and financial statements available to the public upon written request. |
| Software ID: | 11000129 |
| Software Version: | v1.00 |