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.") .... | ||||||
| 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. | 0 | |||||
| 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.. | 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). | ||||||






| 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.") . | 199,668 | 173,208 | 164,821 | 162,589 | 171,990 | 872,276 |
| 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...... | 105,307 | 94,578 | 107,952 | 89,472 | 67,700 | 465,009 |
| 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. | 304,975 | 267,786 | 272,773 | 252,061 | 239,690 | 1,337,285 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | 4,750 | 1,720 | 1,089 | 400 | 7,959 | |
| 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. | 115,832 | 37,197 | 103,851 | 115,035 | 371,915 | |
| c | Add lines 7a and 7b.. | 120,582 | 38,917 | 1,089 | 104,251 | 115,035 | 379,874 |
| 8 | Public Support (Subtract line 7c from line 6.) | 957,411 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 304,975 | 267,786 | 272,773 | 252,061 | 239,690 | 1,337,285 |
| 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.). | 1,337,285 | |||||




| 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 8a | A MEMBER OF THE BOARD TAKES THE MINUTES AND PREPARES A REPORT TO BE APPROVED BY THE FULL BOARD AT THE NEXT MEETING. | |
| Pt VI, Line 11a | MEMBERS ARE PROVIDED A COPY OF THE FORM 990 FOR THEIR REVIEW. ANY QUESTIONS ARE DISCUSSED. | |
| Pt VI, Line 19 | GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE FOR PUBLIC INSPECTION. | |
| Pt VI, Line 8b | THE ORGANIZATION DOES NOT NORMALLY APPOINT COMMITTEES. | |
| Pt VI, Line 12c | BOARD MEMBERS ARE REQUIRED TO REPORT ANY CONFLICTS OF INTEREST TO THE BOARD | |
| Pt XI | PRIOR YEAR ADJUSTMENT FOR PRIOR YEAR OVERSTATEMENT OF DEPRECIATION | |
| Form 990, Part IX, Line 24f | INSURANCE DIVIDEND -1056. 0. -1056. 0. |
| Software ID: | 11000175 |
| Software Version: |