Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (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 listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Total | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | 50,637 | 47,444 | 40,362 | 46,619 | 63,198 | 248,260 |
| 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 | 50,637 | 47,444 | 40,362 | 46,619 | 63,198 | 248,260 |
| 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. | 248,260 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 50,637 | 47,444 | 40,362 | 46,619 | 63,198 | 248,260 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 547 | 461 | 304 | 161 | 236 | 1,709 |
| 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 VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | 249,969 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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 VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
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| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
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|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990-EZ, PART I, LINE 4 - OTHER INVESTMENT INCOME | DESCRIPTION: INTEREST INCOME. AMOUNT: 236. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: AVAIL, INC.. GRANTEE ADDRESS: PO BOX 355 ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 15000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: ANTIGO FAMILY CORNER RESOURCE CENTER. GRANTEE ADDRESS: P.O. BOX 177 ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 1500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: CHILD CARING. GRANTEE ADDRESS: 407 W. MAIN STREET MERRILL, WI 54452. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 1000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: EPILEPSY FOUNDATION HEART OF WISCONSIN. GRANTEE ADDRESS: 1004 FIRST STREET, SUITE 5 STEVENS POINT, WI 54481. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 1100. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: BOYS & GIRLS CLUB OF LANGLADE COUNTY. GRANTEE ADDRESS: 411 SUPERIOR ST ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 15000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: LEROYER HOSPICE & PALLIATIVE CARE. GRANTEE ADDRESS: 112 E. FIFTH AVENUE ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 1000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: HABITAT FOR HUMANITY OF LANGLADE COUNTY. GRANTEE ADDRESS: P.O. BOX 604 ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 3000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: LANGLADE ADULT DAY CARE. GRANTEE ADDRESS: 112 EAST FIFTH AVENUE ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 1000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: LANGLADE COUNTY ASSOCIATION OF EMERGENCY MEDICAL GRANTEE NAME: LANGLADE COUNTY ASSOCIATION OF EMERGENCY MEDICAL. GRANTEE ADDRESS: 605 PARK STREET ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 1000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: ANTIGO AREA COMMUNITY FOOD PANTRY, INC.. GRANTEE ADDRESS: 637 SUPERIOR ST ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 5000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: ALZHEIMER'S ASSOCIATION GREATER WISCONSIN CHAPTER. GRANTEE ADDRESS: 500 1ST STREET, # 2800 WAUSAU, WI 54401. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 1000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: SAMOSET COUNCIL BOY SCOUTS OF AMERICA. GRANTEE ADDRESS: 3511 CAMP PHILLIPS ROAD WESTON, WI 54476. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 1200. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: CHARITABLE. GRANTEE NAME: THE SALVATION ARMY. GRANTEE ADDRESS: 1630 N SUPERIOR ST ANTIGO, WI 54409. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 12/22/14. AMOUNT GIVEN: 5000. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 51800. |
| FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES | DESCRIPTION: DUES. AMOUNT: 575. DESCRIPTION: LICENSES AND PERMITS. AMOUNT: 64. DESCRIPTION: PO BOX RENTAL. AMOUNT: 58. DESCRIPTION: BANK FEES. AMOUNT: 15. DESCRIPTION: CAMPAIGN VIDEO. AMOUNT: 250. TOTAL TO FORM 990-EZ, LINE 16: 962. |
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