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.") .... | 392,618 | 207,813 | 148,364 | 59,888 | 63,201 | 871,884 |
| 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.. | 392,618 | 207,813 | 148,364 | 59,888 | 63,201 | 871,884 |
| 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).. | 446,189 | |||||
| 6 | Public Support. Subtract line 5 from line 4. | 425,695 | |||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 392,618 | 207,813 | 148,364 | 59,888 | 63,201 | 871,884 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 37,704 | 12,109 | 1,654 | 1,500 | 1,072 | 54,039 |
| 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). | 925,923 | |||||






| 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 VI, Line 19 | Governing policies, tax returns, and financial | |
| statements are readily available from LOHO | ||
| office upon request. | ||
| Pt VI, Line 11a | Preparation of tax return is supervised by Treasurer | |
| and other Board members. All Board members are given | ||
| a copy of the return for feedback before filing. | ||
| Pt XII, Line 2c | Financial statements are compiled by a non-independent | |
| CPA. Audits were performed annually after the tax return | ||
| filing deadline through 2010. Treasurer oversees the audit | ||
| and compilations. Because of non-attest activities | ||
| performed, compiling CPA prefers to be listed as | ||
| NOT independent. | ||
| Pt VI, Line 15 | Officers and directors are unpaid. Part-time director | |
| receives nominal salary. Salary for manager | ||
| of senior care facility is based on comparable | ||
| salaries in this geographic area. | ||
| Pt VI, Line 12c | Conflict of interest policy was approved and | |
| incorporated into official by-laws in Dec, 2011. Board | ||
| members are required to report conflicts in writing | ||
| at least annually. The Chair is required to pursue | ||
| any possible unreported conflicts. | ||
| Pt VI, Line 4 | By-laws were amended Dec 2011. Only significant change | |
| was the addition of a formal Conflict of Interest policy. |
| Software ID: | 11000175 |
| Software Version: |