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 (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any unusual grants.) .... | 36,168 | 19,813 | 43,772 | 47,694 | 30,224 | 177,671 |
| 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 | 36,168 | 19,813 | 43,772 | 47,694 | 30,224 | 177,671 |
| 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. | 177,671 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 36,168 | 19,813 | 43,772 | 47,694 | 30,224 | 177,671 |
| 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 VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10. | 177,671 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) |
||||
| 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 | ||||
| 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 2015 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-2015 |
(iii) Distributable Amount for 2015 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2015 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions) |
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| 3 Excess distributions carryover, if any, to 2015: | ||||
| a | ||||
| b | ||||
| c | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2015 distributable amount | ||||
|
i
Carryover from 2010 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2015 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2015 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2015, 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 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
7 Excess distributions carryover to 2016. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a | ||||
| b | ||||
| c Excess from 2013....... | ||||
| d From 2014....... | ||||
| e From 2015....... | ||||
| 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 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: BEAVERCREEK SENIOR CENTER. GRANTEE ADDRESS: 3868 DAYTON-XENIA RD BEAVERCREEK, OH 45432. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 04/21/15. AMOUNT GIVEN: 1,755. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: CIRCLE U HELP CENTER. GRANTEE ADDRESS: 19 NORTH 13TH STREET RICHMOND, IN 47374. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 04/23/15. AMOUNT GIVEN: 252. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: EATON UNITED CHURCH OF CHRIST. GRANTEE ADDRESS: 113 WEST DECATUR ST EATON, OH 45320. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 04/10/15. AMOUNT GIVEN: 390. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: FREESTORE FOODBANK. GRANTEE ADDRESS: 112 EAST LIBERTY ST CINCINNATI, OH 45202. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 05/08/15. AMOUNT GIVEN: 952. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: GENESIS SHLETER - RICHMOND. GRANTEE ADDRESS: 15 S 11TH ST RICHMOND, IN 47374. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 05/06/15. AMOUNT GIVEN: 252. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: GREATER CINCINNATI COALITION FOR THE HOMELESS. GRANTEE ADDRESS: 117 EAST 12TH STREET CINCINNATI, OH 45202. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 05/21/15. AMOUNT GIVEN: 952. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: HOPE HOUSE ADDICTION RECOVERY. GRANTEE ADDRESS: 275 GROVE ROAD RICHMOND, IN 47374. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 05/12/15. AMOUNT GIVEN: 252. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: LEWISBURG UNITED MOETHODIST CHURCH. GRANTEE ADDRESS: PO BOX 7 LEWISBURG, OH 45338. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 03/30/15. AMOUNT GIVEN: 2,435. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: NEW PARIS FOOD PANTRY. GRANTEE ADDRESS: 301 EAST MAIN STREET NEW PARIS, OH 45347. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 04/09/15. AMOUNT GIVEN: 2,263. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: RICHMOND COMMUNITY SERVICE. GRANTEE ADDRESS: 855 N 12TH STREET RICHMOND, IN 47374. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 04/24/15. AMOUNT GIVEN: 252. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: SPRINGBORO FOOD PANTRY. GRANTEE ADDRESS: 1629 S MAIN STREET, SUITE 320 SPRINGBORO, OH 45066. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 05/15/15. AMOUNT GIVEN: 1,220. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: MONTGOMERY COUNTY EMERGENCY HOUSING COALITION. GRANTEE ADDRESS: PO BOX 10082 MID CITY STATION DAYTON, OH 45402. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 04/01/15. AMOUNT GIVEN: 7,379. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: THE FOODBANK. GRANTEE ADDRESS: 56 ARMOR PL DAYTON, OH 45417. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/01/15. AMOUNT GIVEN: 11,068. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: FOOD ASSISTANCE. GRANTEE NAME: XENIA ADULT RECREATION CENTER. GRANTEE ADDRESS: 130 EAST CHURCH ST XENIA, OH 45385. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 03/31/15. AMOUNT GIVEN: 1,755. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 31,177. |
| FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES | DESCRIPTION: OFFICE SUPPLIES. AMOUNT: 507. DESCRIPTION: INSURANCE. AMOUNT: 1,530. DESCRIPTION: MARKETING EXPENSES. AMOUNT: 752. DESCRIPTION: BANK SERVICE CHARGES. AMOUNT: 328. DESCRIPTION: DUES AND LICENSES. AMOUNT: 1,660. DESCRIPTION: SEMINARS AND EDUCATION. AMOUNT: 524. DESCRIPTION: CONFERENCE, CONVENTION AND MEETINGS. AMOUNT: 51. DESCRIPTION: VEHICLE EXPENSE. AMOUNT: 1,111. DESCRIPTION: DEPRECIATION. AMOUNT: 700. DESCRIPTION: PANCAKE BRUNCH PROGRAM EXPENSES. AMOUNT: 15,508. DESCRIPTION: HYGIENE PROGRAM EXPENSES. AMOUNT: 6,992. TOTAL TO FORM 990-EZ, LINE 16: 29,663. |
| FORM 990-EZ, PART I, LINE 20 - OTHER CHANGES IN NET ASSETS | DESCRIPTION: CORRECT NET ASSETS FOR ACCOUNTING CHANGES. AMOUNT: -3,442. |
| FORM 990-EZ, PART II, LINE 24 - OTHER ASSETS | DESCRIPTION: OTHER DEPRECIABLE ASSETS. BEG. OF YEAR AMOUNT: 3,442. END OF YEAR AMOUNT: 2,742. |
| FORM 990-EZ, PART II, LINE 26 - OTHER LIABILITIES | DESCRIPTION: CREDIT CARD. BEG. OF YEAR AMOUNT: 0. END OF YEAR AMOUNT: 3,195. |
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| Software Version: |