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. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
Theodore Roosevelt Medora Foundation
Employer identification number
45-0397662
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
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—2012.
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—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2,185,282
1,596,197
1,909,924
2,326,320
3,873,876
11,891,599
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......
5,126,386
5,460,250
5,029,659
5,402,846
565,790
21,584,931
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.
7,311,668
7,056,447
6,939,583
7,729,166
4,439,666
33,476,530
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
293,020
145,423
264,833
348,464
593,537
1,645,277
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.
143,667
164,807
308,474
c
Add lines 7a and 7b..
293,020
145,423
408,500
513,271
593,537
1,953,751
8
Public support (Subtract line 7c from line 6.)
31,522,779
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
7,311,668
7,056,447
6,939,583
7,729,166
4,439,666
33,476,530
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
188,606
273,741
185,088
110,152
209,575
967,162
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
188,606
273,741
185,088
110,152
209,575
967,162
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.)..
7,500,274
7,330,188
7,124,671
7,839,318
4,649,241
34,443,692
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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
91.520 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
89.510 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
2.810 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
3.030 %
19a
33 1/3% support tests—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
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) 2013
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.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
Theodore Roosevelt Medora Foundation
Employer identification number
45-0397662
Return Reference
Explanation
Form 990, Part VI, Section A, line 1
TRMF has an Executive Committee that meets monthly and is given the authority to act on behalf of the board for any business that may be needed in between the 3 board meetings held during the fiscal year. The Executive Committee is comprised of the Chairman, Vice Chairman, President, Secretary, Treasurer, two directors elected by the board and the immediate past chair of the board for one year after the member ceases to serve as chair of the board. If the current chair is serving consecutive years, the position held for an immediate past chair shall be filled by a board member at large. The President is not on the governing body. The Executive Committee may exercise the authority of the board of directors in the governance of the corporation; provided, however, that the committee shall not have the authority of the board of directors in reference to amending, altering or repealing the by-laws; electing, appointing, or removing any member of the committee or any director or officer of the corporation; amending the articles of incorporation; adopting a plan of merger or adopting a plan of consolidation with another corporation; authorizing the sale, lease, exchange or mortgage of a substantial portion of the property and assets of the corporation; authorizing the voluntary dissolution of the corporation; adopting a plan for the distribution of assets of the corporation; or amending, altering or repealing any resolution provided by the board of directors.
Form 990, Part VI, Section A, line 2
Randy Hatzenbuhler and Frank Larson have a business relationship.
Form 990, Part VI, Section A, line 6
Membership: The Corporation shall have members without voting rights. A member may be an individual, a partnership, a corporation or an unincorporated association. Members shall be divided into various classes and shall qualify as such by payment of annual dues. The classes of membership and the dues for each class shall be established and fixed from time to time by a resolution of the Board of Directors.
Form 990, Part VI, Section B, line 11
A draft of the Form 990 will be reviewed by the CFO and a copy of the draft will be provided electronically to the full board prior to the Form 990 being filed with the IRS.
Form 990, Part VI, Section B, line 12c
On an annual basis, each board member receives and is asked to sign a Board Member Statement of Commitment and Understanding which includes references to the conflict of interest policy. This statement is also discussed at the annual meeting as an agenda item. Conflicts are reviewed at the board level. The person with the conflict is recused from the discussion and voting pertaining to the area of which a conflict exists.
Form 990, Part VI, Section B, line 15
The organization has a Compensation Committee made up of between 4-6 members from the Board of Directors whose responsibility is to annually review compensation and benefits for all employees, including the President and CFO. During this annual review process, comparability data is reviewed along with other information as may be requested by committee members and provided by management. Benefit and incentive plans are also reviewed and approved annually by the Compensation Committee. The deliberation and decision is documented in the meeting minutes.
Form 990, Part VI, Section C, line 19
The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request.
Form 990, Part IX, line 11g
Contract Labor: Program service expenses 453. Management and general expenses 90. Fundraising expenses 32,500. Total expenses 33,043. Other Professional Fees: Program service expenses 5,658. Management and general expenses 78,993. Fundraising expenses 14,367. Total expenses 99,018. Entertainment Contracts & Sales: Program service expenses 654,523. Management and general expenses 0. Fundraising expenses 0. Total expenses 654,523.
Form 990, Part XI, line 9:
Unrealized Gain on Investment in Subsidiary -263,066.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.