TY 2012 Form 990EZ

- TIN:

Form990-EZ
Click to see attachment

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

2012

Open to Public
Inspection

For the 2012 calendar year, or tax year beginning 01-01-2012, and ending 12-31-2012

Check if applicable:

Address change

Name change

Initial return

Terminated

Amended return

Application pending

C Name of organization
ADOPT A FAMILY

Number and street (or P. O. box, if mail is not delivered to street address)PO BOX 2821
Room/suite

City or town, state or country, and ZIP + 4 IOWA CITY, IA52244

D Employer identification number

42-1512146

E Telephone number

(319) 338-2010

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

N/AJ Tax-exempt status(check only one)501(c)(3) Click to see attachment

501(c)( ) 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

$ 55,140

Part I

Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I)Check if the organization used Schedule O to respond to any question in this Part I...................

1	Contributions, gifts, grants, and similar amounts received...............			1	51,771
2	Program service revenue including government fees and contracts ............			2
3	Membership dues and assessments......................			3
4	Investment income...........................			4	268
5a	Gross amount from sale of assets other than inventory........	5a	42
b	Less: cost or other basis and sales expenses...........	5b
c	Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ......			5c	42
6	Gaming and fundraising events
a	Gross income from gaming (attach Schedule G if greater than $15,000) .	6a
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
c	Less: direct expenses from gaming and fundraising events.......	6c
d	Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c)			6d
7a	Gross sales of inventory, less returns and allowances........	7a
b	Less: cost of goods sold.................	7b
c	Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) .........			7c
8	Other revenue (describe in Schedule O) .....................			8	3,059
9	Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8..............			9	55,140
10	Grants and similar amounts paid (list in Schedule O) .................			10	500
11	Benefits paid to or for members........................			11
12	Salaries, other compensation, and employee benefits................			12	19,827
13	Professional fees and other payments to independent contractors............			13	351
14	Occupancy, rent, utilities, and maintenance...................			14
15	Printing, publications, postage, and shipping...................			15	1,159
16	Other expenses (describe in Schedule O) ....................			16	36,431
17	Total expenses. Add lines 10 through 16 .................			17	58,268
18	Excess or (deficit) for the year (Subtract line 17 from line 9)............			18	-3,128
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	46,611
20	Other changes in net assets or fund balances (explain in Schedule O) ..........			20	444
21	Net assets or fund balances at end of year. Combine lines 18 through 20.........			21	43,927

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 10642I Form 990-EZ (2012)

Form 990-EZ (2012)

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.................

(A) Beginning of year(B) End of year

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

40,486

37,711

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

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

6,125

6,216

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

46,611

43,927

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

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

46,611

43,927

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? ORGANIZATION PURCHASES FRESH FOOD FROM LOCAL FARMERS TO BENEFIT LOW INCOME FAMILIES. FAMILIES ARE EDUCATED IN NUTRITION AND AGRICULTURE. ORGANIZATION ALSO DISTRIBUTES PRODUCE TO OTHER NON PROFIT GROUPS.
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 IN 2012 42 HOUSEHOLDS AND 11 NON PROFIT AGENCIES RECEIVED SERVICES FROM LOCAL FOODS CONNECTION. THE HOUSEHOLDS SERVED INCLUDED 60 ADULTS AND 60 CHILDREN; 24 WERE FEMALE HEADED HOUSEHOLDS AND 20 HOUSEHOLDS HAD AT LEAST ONE MEMBER WITH A DISABILITY. FAMILIES COMMIT TO PREPARING GOOD HEALTHY MEALS USING PRODUCED PURCHASED WITH DONATED FUNDS OR DONATED BY LOCAL FARNERS. AGENCIES ENROLLED WERE 4CS HOME TIES DAYCARE, BUILDERS OF HOPE, DOMESTIC VIOLENCE INTERVENTION PROGRAM, ECUMENICAL TOWERS, BILL SACKTER HOUSE, IOWA CITY HEAD START, JOHNSON COUNTY CRISIS CENTER FOOD BANK, PICK A BETTER SNACK FROM IOWA STATE EXTENSION SERVICE, WOMEN, INFANTS AND CHILDREN (WIC) OF JOHNSON COUNTY AND TWO HOME BASED DAYCARE CENTERS. TOTAL SERVED THROUGH THE AGENCIES WERE 800 ADULTS AND 1500 CHILDREN. LOCAL FOODS CONNECTION ALSO GAVE A GRANT TO THE NORTH LIBERTY FOOD PANTRY TO PURCHASE LOCAL FOOD AND EDUCATIONAL MATERIALS. (Grants $ ) If this amount includes foreign grants, check here ...			28a	57,768
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	57,768

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-)
LAURA DOWDEXECUTIVE DI	35.00	7,800
MATT HARTZCHAIR	000.00	0
BETH BENDERBOARD MEMBER	000.00	0
DANA FOSTERSECRETARY	000.00	0
NATALIA ESPINABOARD MEMBER	000.00	0
ANNIE FUNKBOARD MEMBER	000.00	0
MARY MATHEW WILSONBOARD MEMBER	000.00	0
SAM JONESTREASURER	000.00	0

Form 990-EZ (2012)

Page 3

Part V

Other 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

LAURA DOWD Telephone no. bullet

(319) 338-2010

Located at bullet

PO BOX 2821IOWA CITY,IA ZIP + 4 bullet

52244

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 Form 990-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
explanation in 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 Form 990-EZ (see instructions)......................

45b

Form 990-EZ (2012)

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 only All section 501(c)(3) organizations must answer questions 47-49b and 52, and complete the tables for lines 50 and 51 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 as 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
NONE

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
NONE

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 ............... bullet

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 bullet

Firm's EIN bullet

Firm's address bullet

Phone no.

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

YesNo

Form 990-EZ (2012)

Form 990-EZ, Special Condition Description:

Special Condition Description

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

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. right arrow

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

ADOPT A FAMILY

Employer identification number

42-1512146

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.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

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).

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 ..................................................

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

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)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


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

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.") ....	39,574	34,201	48,200	68,301	51,771	242,047
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	39,574	34,201	48,200	68,301	51,771	242,047
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.						242,047

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..	39,574	34,201	48,200	68,301	51,771	242,047
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...	308	108	171	185	311	1,083
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.)..					3,059	3,059
11	Total support (Add lines 7 through 10).						246,189

Gross receipts from related activities, etc. (see instructions) ..................

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........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) .........

98.320 %

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

99.560 %

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 ....................... right arrow

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 ..................... right arrow

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 ..................................................... right arrow

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 ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

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.") .
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.)

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...
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.)..

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............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

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 ........ right arrow

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 ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

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 B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2012

Name of the organization

ADOPT A FAMILY

Employer identification number

42-1512146

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year ......................... Arrow Bullet

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

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

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization ADOPT A FAMILY

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization ADOPT A FAMILY

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

Name of organization
ADOPT A FAMILY

Employer identification number

42-1512146

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

$
Use duplicate copies of Part III if additional space is needed.

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (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.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

ADOPT A FAMILY

Employer identification number

42-1512146

Identifier	Return Reference	Explanation
OTHER REVENUE	FORM 990-EZ, PART I, LINE 8	FUND RAISING ACTIVITES 3,059 TOTAL 3,059
OTHER EXPENSES	FORM 990-EZ, PART I, LINE 16	FUND RAISING ACTIVITES COST OF GOODS SOLD 1,238 EXPENSES ADVERTISING AND PROMOTION 691 OFFICE 1,852 INFORMATION TECHNOLOGY 304 TRAVEL 10 CONFERENCES/MEETINGS 249 INSURANCE 1,083 EDUCATIONAL MATERIALS 4,622 PRODUCE FOR DISTRIBUTION 21,770 KITCHEN WARES TOOLS 2,873 SUBSCRIPTIONS 21 DUES 280 PHOTOGRAPHY 31 GIFTS FOR VOLUNTEERS 174 CARDS 646 NON-INVESTMENT DEPRECIATION 587 TOTAL 36,431
OTHER CHANGES IN NET ASSETS OR FUND BALANCES	FORM 990-EZ, PART I, LINE 20	MARKET INCREASE FOUNDATION 444
OTHER ASSETS	FORM 990-EZ, PART II, LINE 24	EQUIPMENT 2,474 2,711 LESS ACCUMULATED DEPRECIATION 1,257 1,844 JOHNSON COUNTY FOUNDATION 4,908 5,349 TOTAL 6,125 6,216
PRIMARY EXEMPT PURPOSE	FORM 990-EZ, PART III	ORGANIZATION PURCHASES FRESH FOOD FROM LOCAL FARMERS TO BENEFIT LOW INCOME FAMILIES. FAMILIES ARE EDUCATED IN NUTRITION AND AGRICULTURE. ORGANIZATION ALSO DISTRIBUTES PRODUCE TO OTHER NON PROFIT GROUPS.
FIRST ACCOMPLISHMENT	FORM 990-EZ, PART III, LINE 28	IN 2012 42 HOUSEHOLDS AND 11 NON PROFIT AGENCIES RECEIVED SERVICES FROM LOCAL FOODS CONNECTION. THE HOUSEHOLDS SERVED INCLUDED 60 ADULTS AND 60 CHILDREN; 24 WERE FEMALE HEADED HOUSEHOLDS AND 20 HOUSEHOLDS HAD AT LEAST ONE MEMBER WITH A DISABILITY. FAMILIES COMMIT TO PREPARING GOOD HEALTHY MEALS USING PRODUCED PURCHASED WITH DONATED FUNDS OR DONATED BY LOCAL FARNERS. AGENCIES ENROLLED WERE 4CS HOME TIES DAYCARE, BUILDERS OF HOPE, DOMESTIC VIOLENCE INTERVENTION PROGRAM, ECUMENICAL TOWERS, BILL SACKTER HOUSE, IOWA CITY HEAD START, JOHNSON COUNTY CRISIS CENTER FOOD BANK, PICK A BETTER SNACK FROM IOWA STATE EXTENSION SERVICE, WOMEN, INFANTS AND CHILDREN (WIC) OF JOHNSON COUNTY AND TWO HOME BASED DAYCARE CENTERS. TOTAL SERVED THROUGH THE AGENCIES WERE 800 ADULTS AND 1500 CHILDREN. LOCAL FOODS CONNECTION ALSO GAVE A GRANT TO THE NORTH LIBERTY FOOD PANTRY TO PURCHASE LOCAL FOOD AND EDUCATIONAL MATERIALS.

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:

ADOPT A FAMILY

EIN: 42-1512146

Person Name	Explanation
LAURA DOWD
MATT HARTZ
BETH BENDER
DANA FOSTER
NATALIA ESPINA
ANNIE FUNK
MARY MATHEW WILSON
SAM JONES