TY 2011 Form 990EZ

- TIN:

Form990-EZ

Department of the Treasury
Internal Revenue Service

Short Form
Return of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code
(except black lung benefit trust or private foundation)

Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions).
All other organizations with gross receipts less than $200,000 and total assets less than $500,000 at the end of the year may use this form.

The organization may have to use a copy of this return to satisfy state reporting requirements.

OMB No. 1545-1150

2011

Open to Public
Inspection

For the 2011 calendar year, or tax year beginning 04-01-2011, and ending 03-31-2012

Check if applicable:

Address change

Name change

Initial return

Terminated

Amended return

Application pending

C Name of organization
SHAWNEE VALLEY AMBULANCE SERVICE INC

Number and street (or P. O. box, if mail is not delivered to street address)PO BOX 8
Room/suite

City or town, state or country, and ZIP + 4 SCHELLSBURG, PA155590008

D Employer identification number

25-1337935

E Telephone number

(814) 733-4595

F Group Exemption
Number. . bullet

G Accounting method: CashAccrualOther (specify) bullet

H Check bullet

required to attach Schedule B
(Form 990, 990-EZ, or 990-PF).I Website: bullet

http://shawneevalleyambulance.com/J Tax-Exempt status(check only one)501(c)(3) 501(c)( 4) bullet

(insert no.) 4947(a)(1) or 527

K Check

if the organization is not a section 509(a)(3) supporting organization or a section 527 organization and its gross receipts are normally not more than $50,000. A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if the organization chooses to file a return, be sure to file a complete return.

L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts; If gross receipts are $200,000 or more, or if total assets (Part II, line 25, column (B) below) are $500,000 or more,file Form 990 instead of Form 990-EZ........... bullet

$ 157,626


1	Contributions, gifts, grants, and similar amounts received...............			1	10,000
2	Program service revenue including government fees and contracts ............			2	119,696
3	Membership dues and assessments......................			3	20,000
4	Investment income...........................			4	2,559
5a	Gross amount from sale of assets other than inventory........	5a
b	Less: cost or other basis and sales expenses...........	5b	0
c	Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ......			5c	0
6	Gaming and fundraising events
a	Gross income from gaming (attach Schedule G if greater than $15,000) .	6a	0
b	Gross income from fundraising events (not including $ of contributions from fundraising events reported on line 1) (attach Schedule G if the
	sum of such gross income and contributions exceeds $15,000)	6b	1,233
c	Less: direct expenses from gaming and fundraising events.......	6c	1,233
d	Net income or (loss) from gaming and fundraising events (Add lines 6a and 6b and subtract line 6c)			6d	0
7a	Gross sales of inventory, less returns and allowances........	7a
b	Less: cost of goods sold.................	7b	0
c	Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) .........			7c	0
8	Other revenue (describe in Schedule O) .....................			8	4,138
9	Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8.................			9	156,393
10	Grants and similar amounts paid (list in Schedule O) .................			10
11	Benefits paid to or for members........................			11
12	Salaries, other compensation, and employee benefits................			12	49,016
13	Professional fees and other payments to independent contractors............			13	2,000
14	Occupancy, rent, utilities, and maintenance...................			14	7,332
15	Printing, publications, postage, and shipping...................			15
16	Other expenses (describe in Schedule O) ....................			16	75,603
17	Total expenses. Add lines 10 through 16 ....................			17	133,951
18	Excess or (deficit) for the year (Subtract line 17 from line 9)............			18	22,442
19	Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
	end-of-year figure reported on prior year’s return)................			19	267,296
20	Other changes in net assets or fund balances (explain in Schedule O) ..........			20
21	Net assets or fund balances at end of year. Combine lines 18 through 20.........			21	289,738

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 10642I Form 990-EZ (2011)

Form 990-EZ (2011)

Page 2

Part IIBalance Sheets (see the instructions for Part II.)Check if the organization used Schedule O to respond to any question in this Part II.............

(See the instructions for Part II.)(A) Beginning of year(B) End of year

22Cash, savings, and investments................

147,415

158,741

23Land and buildings....................

90,319

100,261

24Other assets (describe in Schedule O) ..........

31,362

32,440

25Total assets......................

269,096

291,442

Total liabilities (describe in Schedule O) .............

1,800

1,704

27Net assets or fund balances (line 27 of column (B) must agree with line 21)..

267,296

289,738

Part IIIStatement of Program Service Accomplishments (see the instructions for Part III.) Check if the organization used Schedule O to respond to any question in this Part III .	Expenses (Required for section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional for others.)
What is the organization's primary exempt purpose? Ambulance svcs to the community
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 PROVIDE AMBULANCE TRANSPORTATION AND RESPONSE TO LOCAL RESIDENTS AND TRAVELERS (Grants $ ) If this amount includes foreign grants, check here ...			28a	132,920
29 (Grants $ ) If this amount includes foreign grants, check here ...			29a
30 (Grants $ ) If this amount includes foreign grants, check here ...			30a
31 Other program services (describe in Schedule O) .................. (Grants $ ) If this amount includes foreign grants, check here...	31a
32 Total program service expenses (add lines 28a through 31a)..............	32	132,920

Part IV List of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated. (see the instructions for Part IV.)Check if the organization used Schedule O to respond to any question in this Part IV..........

(a) Name and title	(b) Average hours per week devoted to position	(c)Reportable compensation (Forms W-2/1099-MISC) (if not paid, enter -0-)
SCOTT COLLINS 394 ROSE RD SCHELLSBURG,PA15559	President2.00	0
RICHARD SHUE 1772 MARKET ST SCHELLSBURG,PA15559	VP2.00	744
BRIAN SWAIN PO BOX 8 SCHELLSBURG,PA15559	Secretary2.00	0
DAN SLACK 147 CHARLES ST SCHELLSBURG,PA15559	Treasurer2.00	0
MIKE BOWMAN PO BOX 8 SCHELLSBURG,PA15559	Board1.00	0
CECILIA CROOP PO BOX 73 SCHELLSBURG,PA15559	Board1.00	0
ADAM DAVIS 4946 MILLIGANS COVE RD MANNS CHOICE,PA15550	Board1.00	230
JAY GREENLEY PO BOX 8 SCHELLSBURG,PA15559	Board1.00	0
DON MACGREGOR 1059 MILL RD SCHELLSBURG,PA15559	Board1.00	0
JC MILLER 1104 MILL RD SCHELLSBURG,PA15559	Board1.00	0
HOLLY SNYDER PO BOX 9 SCHELLSBURG,PA15559	Board1.00	0
TOM WERTZ 616 PONDEROSA RD SCHELLSBURG,PA15559	Board1.00	147
ELAINE CALLIHAN PO BOX 9 SCHELLSBURG,PA15559	Board1.00	0
KEVIN DIEHL 105 S RICHARD ST BEDFORD,PA15522	Board1.00	110
JONI HUFFORD 300 CAMP LIVING WATER RD SCHELLSBURG,PA15559	Board1.00	0

Form 990-EZ (2011)

Page 3

Part VOther Information(Note the Schedule A and personal benefit contract statement requirements in the instructions for Part V.) Check if the organization used Schedule O to respond to any question in this Part V

Yes

Did the organization engage in any significant activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ...................

Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the changeon Schedule O (see instructions). ..........................

35a

Did the organization have unrelated business gross income of $1,000 or more during the year from business activities (such as those reported on lines 2, 6a, and 7a, among others)? ............

35a

If ‘Yes’ to line 35a, has the organization filed a Form 990-T for the year? If ‘No,’ provide an explanation in Schedule O.

35b

Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements during the year? If "Yes," complete Schedule C, Part III.

35c

Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes,” complete applicable parts of Schedule N ................

37a

Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet

37a

Did the organization file Form 1120-POL for this year?...................

37b

38a

Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were

any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?..

38a

If “Yes,” complete Schedule L, Part II and enter the total amount involved .

38b

Section 501(c)(7) organizations. Enter:

Initiation fees and capital contributions included on line 9.......

39a

Gross receipts, included on line 9, for public use of club facilities.....

39b

40a

Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:

section 4911 bullet

; section 4912 bullet

; section 4955 bullet

Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefittransaction during the year or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I. ......

40b

Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958... bullet

Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization.................... bullet

All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T. ......................

40e

41List the states with which a copy of this return is filed. bullet

42aThe organization's books are in care of bullet

DAN SLACK Telephone no. bullet

(814) 733-4595

Located at bullet

PO BOX 8
SCHELLSBURG,PA ZIP + 4 bullet

155590008

At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)?

Yes

42b

If “Yes,” enter the name of the foreign country: bullet

See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.

At any time during the calendar year, did the organization maintain an office outside the U.S.?

42c

If “Yes,” enter the name of the foreign country: bullet

43 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041Check here ....... bullet

and enter the amount of tax-exempt interest received or accrued during the tax year.... bullet

Yes

44a

Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must be completed instead of

Form 990-EZ.................................

44a

Did the organization operate one or more hospital facilities during the year? If ‘Yes,’ Form 990 must be completedinstead of Form990-EZ.............................

44b

Did the organization receive any payments for indoor tanning services during the year?.........

44c

If 'Yes' to line 44c, has the organization filed a Form 720 to report these payments? If ‘No,’ provide an explanationin Schedule O................................

44d

45a

Did the organization have a controlled entity within the meaning of
section 512(b)(13)?............................

45a

45b

Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," Form 990 and Schedule R may need to be completed instead of Form990-EZ (see instructions).....................

45b

Form 990-EZ (2011)

Page 4

Yes

Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition tocandidates for public office? If “Yes,” complete Schedule C, Part I. ..............

Part VI

Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only. All section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b and 52. Check if the organization used Schedule O to respond to any question in this Part VI ...........

Yes

Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II .......................

Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E ....

49a

Did the organization make any transfers to an exempt non-charitable related organization?......

49a

If "Yes," was the related organization a section 527 organization?................

49b

Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."

(a) Name and title of each employee paid more than $100,000	(b) Average hours per week devoted to position	(c) Reportable compensation (Forms W-2/1099-MISC)	(d) Health benefits, contributions to employee benefit plans, and deferred compensation	(e) Estimated amount of other compensation

Total number of other employees paid over $100,000 ................. bullet

Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."

(a) Name and address of each independent contractor paid more than $100,000	(b) Type of service	(c) Compensation

Total number of other independent contractors each receiving over $100,000.......... bullet

Did the organization complete Schedule A? NOTE:All Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A ..................... Yes No

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Sign Here

	Signature of officer	Date

	Type or print name and title

Paid preparer use only

Print/type preparer's name

Preparer's signature

Date

Check if
self-employed

PTIN

Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image

Firm's address Right pointing arrowhead image

Phone no.

May the IRS discuss this return with the preparer shown above? See instructions ......... bullet

YesNo

Form 990-EZ (2011)

Additional Data

Software ID:
Software Version:

Form 990-EZ, Special Condition Description:

Special Condition Description

- 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.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

SHAWNEE VALLEY AMBULANCE SERVICE INC

Employer identification number

25-1337935

Identifier	Return Reference	Explanation
Form 990EZ, Part I, Line 8		OTHER 4138.
Form 990EZ, Part I, Line 16		AMBULANCE 2874. BUILDING MTCE 2866. TELEPHONE 140. FUEL 6717. DRIVER/ATTENDANT COSTS 7818. MEDICAL SUPPLIES 6118. OFFICE SUPPLIES 2765. OFFICE EQUIPMENT 385. PAYROLL TAXES 5012. ALS ASSISTANCE 18400. MEMBERSHIP SUPPLIES 104. INSURANCE 6167. DONATIONS 300. OTHER 364. DEPRECIATION 14540. FUNDRAISING 1033.
Form 990EZ, Part II, Line 24		ANNUITY 31362. 32440.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

Additional Data

Software ID:	11000175
Software Version: