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
LAKE COUNTY CRISIS CENTER - A SAFE PLACE
Employer identification number
36-3032700
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.") ....
1,877,239
1,762,289
2,163,749
1,987,085
1,857,168
9,647,530
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
1,877,239
1,762,289
2,163,749
1,987,085
1,857,168
9,647,530
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)..
16,662
6
Public support. Subtract line 5 from line 4.
9,630,868
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..
1,877,239
1,762,289
2,163,749
1,987,085
1,857,168
9,647,530
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
2,524
223
6,375
369
6,846
16,337
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.)..
110,723
134,694
418,608
196,039
192,988
1,053,052
11
Total support (Add lines 7 through 10).
10,716,919
12
Gross receipts from related activities, etc. (see instructions)
..................
12
175,296
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
89.870 %
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
90.590 %
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.") .
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.)..
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
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
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
LAKE COUNTY CRISIS CENTER - A SAFE PLACE
Employer identification number
36-3032700
Identifier
Return Reference
Explanation
FIRST ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4A
PROTECTION WERE PROVIDED IN ENGLISH AND SPANISH.
SECOND ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4B
THROUGH THIS CRISIS LINE. THE CRISIS LINE AND COUNSELING PROVIDED THROUGH THIS PROGRAM ARE AVAILABLE IN ENGLISH OR SPANISH, ALONG WITH ADDITIONAL LANGUAGE TRANSLATION VIA A LANGUAGE LINE. IN FY13, A SAFE PLACE RESPONDED TO 2,390 CRISIS CALLS.
ALL OTHER ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4D
COMMUNITY AND PREVENTION EDUCATION PROGRAMS IN ADDITION TO THE COUNSELING AND ADVOCACY WORK WE DO, A SAFE PLACE ALSO WORKS TO EDUCATE THE COMMUNITY ABOUT THE DYNAMICS AND EFFECTS OF DOMESTIC VIOLENCE, WHILE RAISING AWARENESS OF THE SERVICES THAT ARE AVAILABLE. EDUCATION AND OUTREACH ARE PROVIDED AT BUSINESSES, RELIGIOUS INSTITUTIONS AND OTHER COMMUNITY GATHERINGS. A SAFE PLACE ALSO EDUCATES PROFESSIONALS SUCH AS SOCIAL WORKERS OR LAW ENFORCEMENT OFFICIALS WHO MAY COME IN CONTACT WITH DOMESTIC VIOLENCE VICTIMS. IN FY2013 A SAFE PLACE PROVIDED 250 PRESENTATIONS TO 5,600 PEOPLE. TO ADDRESS THE ISSUES OF TEEN DATING VIOLENCE, A SAFE PLACE ALSO FACILITATES HEALTHY DATING PRESENTATIONS AT LOCAL SCHOOLS AND AGENCIES TO EDUCATE YOUTH AND TEENS. THESE PRESENTATIONS, WHICH WORK TO PREVENT DOMESTIC VIOLENCE THROUGH EDUCATION ON RED FLAGS, ABUSIVE DYNAMICS AND THE OPTIONS AVAILABLE FOR TEENS, WERE PROVIDED TO 119 YOUTHS IN 2013. ABUSER SERVICES: INTERVENTION PROGRAM FOR DOMESTIC ABUSE AND VIOLENCE (IPDAV) A SAFE PLACE ALSO WORKS TO ELIMINATE DOMESTIC VIOLENCE AND INCREASE THE SAFETY OF VICTIMS BY WORKING DIRECTLY WITH ABUSERS. OUR ABUSER INTERVENTION PROGRAM, IPDAV, PROVIDES A SIX MONTH PROGRAM THAT WORKS WITH THE PERPETRATORS OF ABUSE, TEACHING THEM ACCOUNTABILITY AND HELPING THEM TO EXAMINE AND CHANGE THEIR ABUSIVE BEHAVIORS. IN FY2013, 250 ABUSIVE PARTNERS RECEIVED SERVICES AT IPDAV. PERMANENT SUPPORTIVE HOUSING PROGRAM: AFFORDABLE HOUSING AND ON-SITE SUPPORTIVE SERVICES A SAFE PLACE'S PERMANENT SUPPORTIVE HOUSING PROGRAM (OPENED IN JULY 2011) INCLUDES TWENTY UNITS OF SUBSIDIZED APARTMENT HOUSING ALONG WITH ON-SITE SUPPORTIVE SERVICES AND LIFE SKILLS EDUCATION. THIS HOUSING GIVES VICTIMS OF DOMESTIC VIOLENCE WITH MULTIPLE BARRIERS ADDITIONAL TIME TO REBUILD THEIR LIVES. THE HOUSING ASPECTS OF THIS PROGRAM ARE PROVIDED UNDER THE UMBRELLA OF A SAFE PLACE THROUGH AN ENTITY KNOWN AS A SAFE PLACE II LP (SEE SCHEDULE R), WHILE THE ON-SITE SUPPORTIVE SERVICES ARE PROVIDED WITHIN OUR NON-RESIDENTIAL PROGRAMS.
CLASSES OF MEMBERS OR STOCKHOLDERS
FORM 990, PAGE 6, PART VI, LINE 6
PER BY-LAWS - THE GENERAL MEMBERSHIP SHALL CONSIST OF INDIVIDUALS AND COMMUNITY GROUPS INTERESTED IN AND WHO CONTRIBUTE FINANCIALLY, OR IN-KIND, TO THE ANNUAL OPERATION OF THE ORGANIZATION.
ELECTION OF MEMBERS AND THEIR RIGHTS
FORM 990, PAGE 6, PART VI, LINE 7A
FROM BY-LAWS - DIRECTORS SHALL BE ELECTED BY THE GENERAL MEMBERSHIP AT THE ANNUAL MEETING OF THE MEMBERS. THE ANNUAL MEETING OF THE MEMBERS SHALL BE HELD WITHIN 120 DAYS OF THE CLOSE OF THE FISCAL YEAR. EACH MEMBER PRESENT AT A MEETING, EITHER IN PERSON OR BY PROXY, SHALL BE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO A VOTE OF THE MEMBERS.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990
FORM 990, PAGE 6, PART VI, LINE 11B
THE FINANCE COMMITTEE (COMPRISED OF BOARD MEMBERS) REVIEWS THE COMPLETED FORM 990 AND APPROVES FORWARDING TO THE EXECUTIVE COMMITTEE OF THE BOARD, A COMMITTEE DESIGNATED BY THE BOARD AS HAVING FINAL AUTHORIZATION FOR APPROVAL OF THE FORM 990. THE EXECUTIVE COMMITTEE IS PROVIDED WITH THE COMPLETED FORM 990, MAKES CHANGES AS NECESSARY, AND GIVES FINAL APPROVAL FOR SUBMISSION. THE EXECUTIVE COMMITTEE, AS AUTHORIZED IN THE ORGANIZATION'S BY-LAWS, HAS THE POWER TO ACT FOR THE BOARD WHEN THE BOARD IS UNAVAILABLE OR WHEN DESIGNATED TO DO SO BY THE BOARD. AFTER APPROVAL, THE EXECUTIVE COMMITTEE PROVIDES AN OVERVIEW OF THE FORM 990 CONTENTS AT A REGULARLY SCHEDULED BOARD MEETING.
ENFORCEMENT OF CONFLICTS POLICY
FORM 990, PAGE 6, PART VI, LINE 12C
IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS. AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE GOVERNING BOARD OR COMMITTEE MEETING, BUT AFTER THE PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT INVOLVING THE POSSIBLE CONFLICT OF INTEREST. IN ADDITION, ALL INTERESTED PERSONS MUST COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE (PRIOR TO) UPON BECOMING AN OFFICER OR UPON JOINING THE BOARD OF DIRECTORS OR ANY COMMITTEE AND AT LEAST ANNUALLY THEREAFTER. THE EXECUTIVE DIRECTOR WILL ENSURE THAT THIS TAKES PLACE AND BRING ANY POTENTIAL CONFLICTS TO THE EXECUTIVE COMMITTEE'S ATTENTION.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION
FORM 990, PAGE 6, PART VI, LINE 19
GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST BY WRITTEN REQUEST AND/OR REVIEW ON THE ORGANIZATION'S PREMISES.
CHANGE IN FINANCIAL REVIEW PROCESS
FORM 990, PAGE 12, PART XII, LINE 2C
THERE WERE NO CHANGES IN THE REVIEW PROCESS IN FY2013
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.