Form Schedule G (Form 9 Schedule G (Form 9 Supplemental Information Regarding Fundraising or Gaming

SCHEDULE G
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered “Yes” to Form 990, Part IV, lines 17, 18, or 19, or if the
organization entered more than $15,000 on Form 990-EZ, line 6a.
© Attach to Form 990 or Form 990-EZ. © See separate instructions.

Name of the organization

Part I
1
a
b
c
d

OMB No. 1545-0047

2009
Open To Public
Inspection

Employer identification number

Fundraising Activities. Complete if the organization answered “Yes” to Form 990, Part IV, line 17.
Form 990-EZ filers are not required to complete this part.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.
Mail solicitations
e
Solicitation of non-government grants
Internet and email solicitations
f
Solicitation of government grants
Phone solicitations
g
Special fundraising events
In-person solicitations

2a Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

No

b If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.
(i) Name of individual
or entity (fundraiser)

(ii) Activity

(iii) Did fundraiser have
custody or control of
contributions?

Yes

Total

(iv) Gross receipts
from activity

(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i)

(vi) Amount paid to
(or retained by)
organization

No

©

3 List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from
registration or licensing.

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2009

Schedule G (Form 990 or 990-EZ) 2009

Revenue

Part II

1

Gross receipts

2

Less: Charitable
contributions
Gross income (line 1
minus line 2)

Direct Expenses

3

4

Cash prizes

5

Noncash prizes

6

Rent/facility costs

7

Food and beverages

8

Entertainment

9

Other direct expenses

10
11

Direct Expenses

Revenue

Part III

Page

2

Fundraising Events. Complete if the organization answered “Yes” to Form 990, Part IV, line 18, or reported
more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

(b) Event #2

(c) Other events

(event type)

(event type)

(total number)

(d) Total events
(add col. (a) through
col. (c))

©

Direct expense summary. Add lines 4 through 9 in column (d)
Net income summary. Combine line 3, column (d), and line 10

(

)

©

Gaming. Complete if the organization answered “Yes” to Form 990, Part IV, line 19, or reported more
than $15,000 on Form 990-EZ, line 6a.
(a) Bingo

(b) Pull tabs/instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (add
col. (a) through col. (c))

1

Gross revenue

2

Cash prizes

3

Noncash prizes

4

Rent/facility costs

5

Other direct expenses

6

Volunteer labor

7

Direct expense summary. Add lines 2 through 5 in column (d)

©

8

Net gaming income summary. Combine line 1, column d, and line 7

©

Yes
No

%

Yes
No

%

Yes
No

%

(

)

Yes No
9 Enter the state(s) in which the organization operates gaming activities:
a Is the organization licensed to operate gaming activities in each of these states?
b If “No,” explain:

9a

10a Were any of the organization’s gaming licenses revoked, suspended or terminated during the tax year?
b If “Yes,” explain:

11
12

Does the organization operate gaming activities with nonmembers?
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming?

10a

11
12

Schedule G (Form 990 or 990-EZ) 2009

Schedule G (Form 990 or 990-EZ) 2009

Page

3

Yes No
13
a
b
14

Indicate the percentage of gaming activity operated in:
%
13a
The organization’s facility
%
13b
An outside facility
Enter the name and address of the person who prepares the organization’s gaming/special events books
and records:
Name

©

Address

©

15a Does the organization have a contract with a third party from whom the organization receives gaming
revenue?
b If “Yes,” enter the amount of gaming revenue received by the organization © $
and the
.
amount of gaming revenue retained by the third party © $
c If “Yes,” enter name and address of the third party:
Name

©

Address
16

15a

©

Gaming manager information:
Name

©

Gaming manager compensation

©

Description of services provided

©

Director/officer

$

Employee

Independent contractor

17 Mandatory distributions:
a Is the organization required under state law to make charitable distributions from the gaming proceeds to
17a
retain the state gaming license?
b Enter the amount of distributions required under state law to be distributed to other exempt organizations
or spent in the organization’s own exempt activities during the tax year © $
Schedule G (Form 990 or 990-EZ) 2009