Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 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 |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | 433,074 | 151,576 | 140,703 | 137,692 | 79,669 | 942,714 |
| 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 | 433,074 | 151,576 | 140,703 | 137,692 | 79,669 | 942,714 |
| 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).. | 51,672 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 891,042 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 433,074 | 151,576 | 140,703 | 137,692 | 79,669 | 942,714 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 149,828 | 126,419 | 135,849 | 170,499 | 145,404 | 727,999 |
| 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 | 1,670,713 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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) |
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| 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): |
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| 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 2019 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-2019 |
(iii) Distributable Amount for 2019 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2019 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2019: | ||||
| a From 2014....... | ||||
| b From 2015....... | ||||
| c From 2016....... | ||||
| d From 2017....... | ||||
| e From 2018....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2019 distributable amount | ||||
|
i
Carryover from 2014 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2019 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2019 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2020. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2015..... | ||||
| b Excess from 2016..... | ||||
| c Excess from 2017..... | ||||
| d Excess from 2018..... | ||||
| e Excess from 2019..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| SCHEDULE A, PART II: | SOME OF THE PRIOR YEAR AMOUNTS IN SCHEDULE A, PART II, HAVE BEEN RESTATED TO MORE ACCURATELY REFLECT THE REVENUE AMOUNTS REPORTED IN THE PART VIII STATEMENT OF REVENUE IN THE TAXPAYER'S PRIOR YEAR FORMS 990. |
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART III, LINE 2 | APPLIED BEHAVIORAL ANALYSIS: THIS NEW PROGRAM PROVIDES A UNIQUE THERAPY FOR INDIVIDUALS DIAGNOSED WITH AUTISM SPECTRUM DISORDER DESIGNED TO IMPROVE BEHAVIORAL AND COGNITIVE SKILLS. SERVICES ARE PROVIDED BY REGISTERED BEHAVIOR TECHNICIANS AND ARE OVERSEEN BY A BOARD CERTIFIED BEHAVIOR ANALYST. THERAPY IS TAILORED TO EACH INDIVIDUALS' PLAN WHICH IS BASED ON AN ASSESSMENT OF CURRENT SKILLS AND GOALS FOR DEVELOPMENT. THE ORGANIZATION HAS YET TO BEGIN SERVING ANY INDIVIDUALS IN THIS PROGRAM. |
| FORM 990, PART III, LINE 4A, DESCRIPTION OF PROGRAM SERVICE: | FAMILY INFANT AND TODDLER: EARLY INTERVENTION - SERVED 588 FAMILIES WITH INFANTS, AGE RANGE OF BIRTH TO THREE YEARS OF AGE, WHO HAVE A DEVELOPMENTAL DISABILITY, DELAY, OR ARE AT RISK FOR A DELAY. SERVICES OFFERED HELP PARENTS HELP THEIR CHILDREN REACH THEIR POTENTIAL AND TAKE PART IN FAMILY, SCHOOL AND COMMUNITY ACTIVITIES. SERVICES INCLUDE DEVELOPMENTAL SERVICES, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, COUNSELING, SERVICE COORDINATION, SCREENING, ASSESSMENT, AND EVALUATION. |
| FORM 990, PART III, LINE 4B, DESCRIPTION OF PROGRAM SERVICE: | RESPITE: THESE PROGRAMS PROVIDE FAMILY-CENTERED SERVICES THAT UTILIZE THE INSIGHTS AND EXPERIENCES OF FAMILY MEMBERS. THESE PROGRAMS SERVE INFANTS, CHILDREN, AND ADULTS WHO MEET ELIGIBILITY REQUIREMENTS. THIS PROGRAM PROVIDES TWO MODELS: PROVIDER MODEL RESPITE - THIS MODEL IS SHORT-TERM TEMPORARY CARE BY A TRAINED RESPITE PROVIDER EITHER IN THE HOME OF THE FAMILY, THE PROVIDER'S HOME, OR IN THE COMMUNITY. THIS IS A FLEXIBLE SERVICE AND THE INDIVIDUAL SERVED AND THE FAMILY CHOOSE WHEN AND HOW TO USE THE SERVICES. THE NUMBER OF INDIVIDUALS SERVED WAS 67. RECREATIONAL RESPITE - THIS MODEL IS SHORT-TERM CARE WITH TRAINED STAFF TO DELIVER OPPORTUNITIES FOR RECREATIONAL SPORTS ACTIVITIES TO PROVIDE A BREAK FROM CAREGIVING TO THEIR FAMILIES AND ALSO PROVIDE SOCIAL SKILL OPPORTUNITIES FOR THE CHILD. THE NUMBER OF INDIVIDUALS SERVED WAS 17. |
| FORM 990, PART III, LINE 4C, DESCRIPTION OF PROGRAM SERVICE: | FAMILY LIVING: THIS IS A HOME-BASED PROGRAM THAT PROVIDES 24/7 CARE TO ENABLE ADULT INDIVIDUALS TO REMAIN LIVING IN THEIR OWN HOME, THEIR FAMILY HOME, OR A SURROGATE HOME TO PROMOTE INDEPENDENCE, COMMUNITY INCLUSION, AND AN ENHANCED QUALITY OF LIVING. DAILY SERVICES INCLUDE DAILY LIVING SKILLS, COMMUNITY ACTIVITIES, AND ANY GOALS SET BY THE INDIVIDUAL AND THEIR TEAM OF SUPPORT. THE NUMBER OF INDIVIDUALS SERVED WAS 4. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE PRESIDENT AND EXECUTIVE DIRECTOR REVIEW FORM 990 AND FINANCIAL STATEMENTS, THEN IT IS PRESENTED TO THE BOARD FOR APPROVAL. ALL MEMBERS OF THE BOARD RECEIVE A COMPLETE COPY OF THE FORM 990 PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE POLICY IS REVIEWED AND UPDATED ANNUALLY AT BOARD MEETING. |
| FORM 990, PART VI, SECTION B, LINE 15A | A REPORT INCLUDING COMPARATIVE DATA IS PROVIDED TO THE BOARD FOR REVIEW WHEN DETERMINING COMPENSATION OF THE EXECUTIVE DIRECTOR. THE INDEPENDENT BOARD THEN REVIEWS AND APPROVES THE AGREED UPON COMPENSATION PACKAGE. CONTEMPORANEOUS MINUTES OF THE DELIBERATION AND DECISION ARE MAINTAINED. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. |
| FORM 990, PART IX, LINE 11G | THERAPISTS: PROGRAM SERVICE EXPENSES 431,452. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 431,452. RESPITE PROVIDERS: PROGRAM SERVICE EXPENSES 95,658. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 95,658. FAMILY LIVING PROVIDERS: PROGRAM SERVICE EXPENSES 84,612. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 84,612. SUBCARE PROVIDERS: PROGRAM SERVICE EXPENSES 10,857. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,857. |
| FORM 990, PART IX, LINE 24E | PROGRAM ACTIVITIES: PROGRAM SERVICE EXPENSES 3,398. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,398. TAXES, LICENSES AND FEES: PROGRAM SERVICE EXPENSES 155. MANAGEMENT AND GENERAL EXPENSES 3,220. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,375. EMPLOYEE EXPENSE: PROGRAM SERVICE EXPENSES 411. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 411. BOARD EXPENSES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 364. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 364. IN-KIND USE OF FACILITIES: PROGRAM SERVICE EXPENSES -2,400. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES -2,400. |
| FORM 990, PART XII, LINE 2C: | THERE HAS BEEN NO CHANGE IN EITHER THE OVERSIGHT PROCESS OR THE SELECTION PROCESS DURING THE TAX YEAR. |
| Software ID: | |
| Software Version: |