Form Schedule J (F 990) Schedule J (F 990) Compensation Information

SCHEDULE J
(Form 990)
Department of the Treasury
Internal Revenue Service

2009

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
© Complete if the organization answered “Yes” to Form 990,
Part IV, line 23.
© Attach to Form 990. © See separate instructions.

Name of the organization

Part I

OMB No. 1545-0047

Compensation Information

Open to Public
Inspection

Employer identification number

Questions Regarding Compensation
Yes

No

1a Check the appropriate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Travel for companions
Tax indemnification and gross-up payments
Discretionary spending account

Housing allowance or residence for personal use
Payments for business use of personal residence
Health or social club dues or initiation fees
Personal services (e.g., maid, chauffeur, chef)

b If any of the boxes on line 1a are checked, did the organization follow a written policy regarding payment
or reimbursement or provision of all of the expenses described above? If “No,” complete Part III to
explain
2 Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a?
3

1b
2

Indicate which, if any, of the following the organization uses to establish the compensation of the
organization’s CEO/Executive Director. Check all that apply.
Compensation committee
Written employment contract
Compensation survey or study
Independent compensation consultant
Approval by the board or compensation committee
Form 990 of other organizations

4

During the year, did any person listed in Form 990, Part VII, Section A, line 1a, with respect to the filing
organization or a related organization:
a Receive a severance payment or change-of-control payment?
b Participate in, or receive payment from, a supplemental nonqualified retirement plan?
c Participate in, or receive payment from, an equity-based compensation arrangement?
If “Yes” to any of lines 4a–c, list the persons and provide the applicable amounts for each item in Part III.

5
a
b
6
a
b
7
8

9

Only section 501(c)(3) and 501(c)(4) organizations must complete lines 5–9.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
The organization?
Any related organization?
If “Yes” to line 5a or 5b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
The organization?
Any related organization?
If “Yes” to line 6a or 6b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If “Yes,” describe in Part III
Were any amounts reported in Form 990, Part VII, paid or accrued pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If “Yes,” describe
in Part III
If “Yes” to line 8, did the organization also follow the rebuttable presumption procedure described in
Regulations section 53.4958-6(c)?

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

4a
4b
4c

5a
5b

6a
6b

7

8
9

Schedule J (Form 990) 2009

Schedule J (Form 990) 2009

Part II

Page

2

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)–(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(B) Breakdown of W-2 and/or 1099-MISC compensation
(i) Base
compensation

(A) Name

(ii) Bonus & incentive
compensation

(iii) Other
reportable
compensation

(C) Retirement and
other deferred
compensation

(D) Nontaxable
benefits

(E) Total of columns
(B)(i)–(D)

(F) Compensation
reported in prior
Form 990 or
Form 990-EZ

(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
Schedule J (Form 990) 2009

Page 3
Supplemental Information
Part III
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part
for any additional information.
Schedule J (Form 990) 2009

Schedule J (Form 990) 2009