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.") . | 150,199 | 138,582 | 85,388 | 98,430 | 98,144 | 570,743 |
| 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...... | 167,813 | 194,410 | 242,706 | 197,354 | 250,734 | 1,053,017 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | 0 | |||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | 0 | |||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | 0 | |||||
| 6 | Total. Add lines 1 through 5. | 318,012 | 332,992 | 328,094 | 295,784 | 348,878 | 1,623,760 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | 25,250 | 12,750 | 7,450 | 12,750 | 2,150 | 60,350 |
| 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. | 134,508 | 177,045 | 214,595 | 182,405 | 237,111 | 945,664 |
| c | Add lines 7a and 7b.. | 159,758 | 189,795 | 222,045 | 195,155 | 239,261 | 1,006,014 |
| 8 | Public Support (Subtract line 7c from line 6.) | 617,746 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 318,012 | 332,992 | 328,094 | 295,784 | 348,878 | 1,623,760 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 14,133 | 5,714 | 7,529 | 7,154 | 4,432 | 38,962 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 14,133 | 5,714 | 7,529 | 7,154 | 4,432 | 38,962 |
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | 0 | |||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | 0 | |||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | 332,145 | 338,706 | 335,623 | 302,938 | 353,310 | 1,662,722 |




| Facts And Circumstances Test |
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| Explanation |
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| Software ID: | 11000144 |
| Software Version: | 2011v1.5 |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Form 990, Part VI, Line 19 | Form 990, Part VI, Line 19: Other Organization Documents Publicly Available | DOCUMENTS AVAILABLE UPON REQUEST. |
| Form 990, Part VI, Line 11 | Form 990, Part VI, Line 11: Form 990 Review Process | THE BOARD WILL BE PROVIDED A COPY OF THE FORM 990 AT THEIR ANNUAL MEETING. |
| Form 990, Part VI, Line 7b | Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders | APPROVAL OF THE BUDGET AND ELECTION OF OFFICERS. |
| Form 990, Part VI, Line 2 | Form 990, Part VI, Line 2: Description of Business or Family Relationship of Officers, Directors, Et | Doug Frye, MD and Mark Penn, DC -- Business RelationshipApril Harris, DO and Mary Stewart, MTS, APRN -- Business RelationshipJim Barnett, MD; Ray Lumb, MD; and Ed Wood, MD -- Business Relationship |
| Software ID: | 11000144 |
| Software Version: | 2011v1.5 |