Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
BASAL CELL CARCINOMA NEVUS SYNDROME LIFE SUPPORT NETWORK
Employer identification number
34-1915691
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(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 monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here........................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2011.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
106,556
155,994
194,431
199,232
187,170
843,383
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......
699
3,433
22,184
36,300
28,899
91,515
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.
107,255
159,427
216,615
235,532
216,069
934,898
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
99,000
98,500
149,000
102,000
45,000
493,500
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..
99,000
98,500
149,000
102,000
45,000
493,500
8
Public support (Subtract line 7c from line 6.)
441,398
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
9
Amounts from line 6...
107,255
159,427
216,615
235,532
216,069
934,898
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
125
125
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
125
125
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.)..
107,255
159,427
216,615
235,532
216,194
935,023
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
47.210 %
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
36.840 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
0 %
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2012.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2011.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
Software Version:
-
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.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
BASAL CELL CARCINOMA NEVUS SYNDROME LIFE SUPPORT NETWORK
Employer identification number
34-1915691
Identifier
Return Reference
Explanation
OTHER EXPENSES
FORM 990-EZ, PART I, LINE 16
EXPENSES PUBLIC RELATIONS 149 SUPPLIES 3,754 SOFTWARE 740 UNIFORMS 167 PROFESSIONAL MEMBERSHIP FEES 530 CONFERENCE/CONVENTION 34,177 MEMBER MEETINGS 24,602 TRAVEL 1,999 INSURANCE 2,019 CONTRACT SERVICES 119,150 SPECIAL EVENT EXPENSES 203 OFFICE EQUIPMENT 463 EDUCATIONAL MATERIALS 1,067 WEBSITE 1,032 FUNDRAISING CONSULTATION 9,500 FORGIVE RELATED PARTY REC 8,300 STRATEGIC CONSULTATION 5,000 RESEARCH AND TRIALS 7,968 VIDEO 7,988 NON-INVESTMENT DEPRECIATION 2,686 TOTAL 231,494
OTHER ASSETS
FORM 990-EZ, PART II, LINE 24
PLEDGES RECEIVABLE 57,210 30,980 LESS ALLOWANCE 0 8,300 NET 57,210 22,680 OFFICE EQUIPMENT 13,427 13,578 LESS ACCUMULATED DEPRECIATION 3,813 6,499 WEBSITE 5,387 5,387 LESS ACCUMULATED AMORTIZATION 1,795 3,589 TOTAL 70,416 31,557
OTHER LIABILITIES
FORM 990-EZ, PART II, LINE 26
ACCOUNTS PAYABLE AND ACCRUED EXPENSES 38,761 51,764
PRIMARY EXEMPT PURPOSE
FORM 990-EZ, PART III
THE MISSION OF THE BCCNS LIFE SUPPORT NETWORK IS TO: FOCUS ON THE EARLY DIAGNOSIS AND TREATMENT OF CHILDREN EVIDENCING AN INITIAL ONSET OF BCCNS; DEVELOP INFORMATION ABOUT THE MEDICAL CONDITIONS AND DISORDERS EXPERIENCED BY THOSE LIVING WITH BCCNS; SHARE THIS INFORMATION WITH CLINICS AND HEALTHCARE PROVIDERS TREATING BCCNS PATIENTS, AND OTHER SIMILARLY AFFECTED POPULATIONS; ENGAGE AFFECTED INDIVIDUALS AND THEIR FAMILIES, CAREGIVERS, COLLEAGUES, AND SCHOOLS IN CREATIVE LEARNING OPPORTUNITIES TO EFFECT AN OPTIMUM QUALITY OF LIFE AND ATTAIN MAXIMUM PERSONAL POTENTIALS THROUGH INFORMED COMMUNICATION; STRENGTHEN THE CAPACITY OF PATIENTS AND THEIR FAMILIES TO MANAGE THEIR DISEASE; AND ESTABLISH AND FOSTER A NETWORK OF MEDICAL PROFESSIONALS ACTIVELY ENGAGED IN ADVANCING THE WELFARE OF THE BCCNS PATIENT COMMUNITY.
FIRST ACCOMPLISHMENT
FORM 990-EZ, PART III, LINE 28
THE NETWORK ATTENDED THE FOLLOWING MEDICAL PROFESSIONAL MEETINGS IN 2012 TO EDUCATE MORE HEALTHCARE PROVIDERS ABOUT THE TOOLS FOR DIAGNOSIS, EARLY INTERVENTION AND TREATMENT /MANAGEMENT PROTOCOLS: "AMERICAN ACADEMY OF DERMATOLOGY; ADVOCACY BOOTH; PANEL SPEAKER "AMERICAN SOCIETY OF CLINICAL ONCOLOGY; ADVOCACY BOOTH "SOCIETY FOR INVESTIGATIVE DERMATOLOGY; NETWORK HOSTED "HEDGEHOG: HEAD TO TOE", MEDICAL SYMPOSIUM "INTL. SYMPOSIUM ON PED. NEURO-ONCOLOGY; ADVOCACY BOOTH & COMMENTATOR "AAD RESEARCH AGENDA CONSENSUS CONFERENCE ""ONE VOICE AGAINST CANCER" LOBBY DAY IN CONJUNCTION WITH: AMERICAN ACADEMY OF DERMATOLOGY; AMERICAN CANCER SOCIETY; LANCE ARMSTRONG FOUNDATION AND OVER 30 OTHER ORGANIZATIONS, HELD IN WASHINGTON, DC. BCCNS NETWORK WAS ABLE TO HOST THREE REGIONAL MEETINGS (RALEIGH, NC; BOIS BLANC ISLAND, MI; BURTON, OH) THIS YEAR WITH THE GRANT SUPPORT FROM NOVARTIS. WE ALSO CONDUCTED A MEDICAL SYMPOSIUM, "HEDGEHOG: HEAD TO TOE", AT THE SOCIETY FOR INVESTIGATIVE DERMATOLOGY ANNUAL MEETING. THE "YOU ARE NOT ALONE" OUTREACH PROGRAM ENCOMPASSED PEOPLE NATIONWIDE AND GLOBALLY, ESPECIALLY TARGETING UNDER-SERVED POPULATIONS AND AT-RISK COMMUNITIES - THOSE WHO WOULD OTHERWISE LACK ACCESS TO RELIABLE INFORMATION CONCERNING THIS COMPLEX ORPHAN CONDITION. THROUGH ATTENDANCE AT THE ABOVE MENTIONED REGIONAL MEMBER/PROFESSIONAL MEETINGS AND SYMPOSIUM, WE HAD DIRECT CONTACT WITH OVER 675 DISTINCT INDIVIDUALS. THE EDUCATIONAL PROGRAMMING REACHES 1,000'S MORE THROUGH DISTRIBUTION OF DISEASE SPECIFIC MATERIALS, CLINICAL TRIAL PARTICIPATION, MEDICAL PROFESSIONAL CONFERENCES, ONLINE SOCIAL MEDIA AVENUES AND DIRECT CONTACT VIA TELEPHONE, E-MAIL, WEBSITE AND IN-PERSON INTERACTION. WE IDENTIFIED AND INVOLVED 2 NEW MEDICAL ADVISORY BOARD MEMBERS. 2012 ALSO MARKED A MILESTONE AFTER ENROLLING 42 MEMBERS WHO PRESENTED OVER 2,000 BCCS FOR A SUCCESSFUL CLINICAL TRIAL, THE FDA APPROVED A NEW DRUG, VISMODEGIB, (TRADE NAME ERIVEDGE BY GENENTECH, A ROCHE GROUP) AS THE FIRST IN CLASS FOR SYSTEMIC GENETIC HEDGEHOG INHIBITOR TREATMENT FOR ADULTS WITH INVASIVE BCC. HUNDREDS OF PERSONS WITH ADVANCED AND METASTATIC BCCS, ARE NOW BENEFITTING FROM THIS CHEMO THERAPEUTIC. POST CONFERENCE AND REGIONAL MEETING EVALUATIONS WERE COMPLETED BY 82% OF ATTENDEES AND OFFERED INSIGHT FOR FUTURE PROGRAMMING AND NEEDS ASSESSMENT. SATISFACTION WAS 90 PLUS IN 92 PERCENTILE OF ATTENDEES FOR ALL VENUES. COLLATERAL MATERIALS, NEWSLETTERS, EDUCATIONAL ARTICLES, INFORMATION ON CLINICAL TRIALS, ONLINE FORUM AND SOCIAL MEDIA AVENUES ARE AVAILABLE THROUGH THE NETWORK'S ORGANIZATIONAL WEBSITE WHICH RECEIVES 6,212 UNIQUE VISITORS AND 10,029 VISITS ANNUALLY WITH 29,605 PAGE VIEWS. OUR EXECUTIVE DIRECTOR, KRISTI SCHMITT BURR, SERVES AS A MEMBER OF: FOOD AND DRUG ADMINISTRATION (FDA) PATIENT REPRESENTATIVE; COMMISSION ON DENTAL ACCREDITATION (CODA) PUBLIC MEMBER; THE CONGRESSIONALLY DIRECTED MEDICAL RESEARCH PROGRAM FOR THE DEPT. DEFENSE. THE SUPPORT NETWORK IS A MEMBER IN GOOD STANDING OF: DERMATOLOGY NURSES ASSOCIATION; NATIONAL ORGANIZATION FOR RARE DISORDERS; COALITION OF SKIN DISEASES; AND GENETIC ALLIANCE. OUR PROGRAM DIRECTORS AND STAFF HAVE BEEN ABLE TO EXPAND INTERACTIVE PROGRAMMING AND SERVICES BY CONNECTING AFFECTED INDIVIDUALS, THEIR FAMILIES, CAREGIVERS, AND THE PROFESSIONALS WHO CARE FOR THEM THROUGH THE CREATION OF DIDACTIC LEARNING SESSIONS. SUCCESSFUL COLLABORATION HAS ALLOWED US THE OPPORTUNITY TO: 1.FOCUS ON THE EARLY DIAGNOSIS AND TREATMENT OF CHILDREN; 2.AUTHOR & PUBLISH DIAGNOSIS AND TREATMENT PROTOCOLS IN THE AMERICAN JOURNAL OF MEDICAL GENETICS AND GENETICS IN MEDICINE THROUGH COLLABORATION EFFORTS WITH: DR. VIRGINIA KIMONIS, UNIV. OF CA, IRVINE; DR. ALANNA BREE, TX;& DR. MAULIK SHAH, FL; 3.AUGMENT DIRECT COMMUNICATION AND MEMBER OUTREACH INCREASING OUR FAMILY MEMBERSHIP BY 62 NEW FAMILIES THIS YEAR (EACH WITH MULTIPLE AFFECTED FAMILY MEMBERS); 4.FOSTER RESPONSIBILITY THROUGH UNDERSTANDING OF TREATMENT OPTIONS; 5.HOST THREE EDUCATIONAL RETREATS AND MEMBER MEETINGS IN 2012, REACHING MANY, WHO IN THE PAST HAVE NOT BEEN ABLE TO ATTEND DUE TO FINANCIAL CONSTRAINTS; 6.ATTEND PROFESSIONAL MEETINGS TO EDUCATE CLINICIANS, RESEARCHERS, PROFESSORS AND DEPARTMENT CHAIRS AND SUPPLEMENT THEIR AWARENESS OF THIS CONDITION, MANIFESTATIONS, TREATMENT OPTIONS AND CLINICAL TRIAL OPPORTUNITIES. THESE EXPERIENCES HAVE PROVIDED US WITH INVALUABLE CONTACTS AND RESOURCES.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
Software Version:
-
TIN:
TY 2012 CompensationExplanation
Name:
BASAL CELL CARCINOMA NEVUS
SYNDROME LIFE SUPPORT NETWORK
EIN: 34-1915691
Person Name
Explanation
MICHAEL RAINEN
WILLIAM GINN
BRYANT BRADLEY
JULIE BRENEISER
KRISTI SCHMITT BURR
AN UNRELATED ENTITY EMPLOYS THE INDIVIDUALS WHO DIRECT THE ACTIVITIES OF THE ORGANIZATION AND THEREFORE THERE ARE NO W2S ISSUED COMPENSATION PAID BY THE UNRELATED ENTITY IS REIMBURSED BY THE ORGANIZATION ON A REGULAR BASIS PAYROLL TAXES ON THIS COMPENSATION ARE REMITTED TO THE TAX AUTHORITIES BY THE UNRELATED ENTITY REIMBURSEMENTS FOR COMPENSATIONARE CLASSIFIED AS CONTRACTED SERVICES IN SCHEDULE O TOTAL 2012 COMPENSATION PAID TO THE EXECUTIVE DIRECTOR WAS 48000 HOSPITALIZATION AND OTHER BENEFITS PAID ON BEHALF OF THE EXECUTIVE DIRECTOR AMOUNTED TO 13910 FOR 2012