Form 990-EZ Short Form Return of Organization Exempt From Income Tax

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Form

990-EZ

Department of the Treasury
Internal Revenue Service

Short Form
Return of Organization Exempt From Income Tax

Address change

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, 2011, and ending

Amended return

G Accounting Method:

E Telephone number

City or town, state or country, and ZIP + 4

Application pending

Cash

I Website: ▶
J Tax-exempt status (check only one) —

Accrual

Other (specify)

Open to Public
Inspection

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D Employer identification number

Room/suite

Number and street (or P.O. box, if mail is not delivered to street address)

Initial return
Terminated

2011

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code
(except black lung benefit trust or private foundation)
▶ Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities,
and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions).
All other organizations with gross receipts less than $200,000 and total assets less than $500,000
at the end of the year may use this form.
▶ The organization may have to use a copy of this return to satisfy state reporting requirements.

A For the 2011 calendar year, or tax year beginning
C Name of organization
B Check if applicable:
Name change

OMB No. 1545-1150

F Group Exemption
Number ▶

H Check ▶
if the organization is not
required to attach Schedule B
(Form 990, 990-EZ, or 990-PF).
527

▶

501(c)(3)
501(c) (
) ◀ (insert no.)
4947(a)(1) or
if the organization is not a section 509(a)(3) supporting organization or a section 527 organization and its gross receipts are normally
K Check ▶
not more than $50,000. A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if
the organization chooses to file a return, be sure to file a complete return.
L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part II,
line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ

Net Assets

Expenses

Revenue

Part I
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Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I.)

Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . . . .

Contributions, gifts, grants, and similar amounts received . . . . . . . . . . . . .
Program service revenue including government fees and contracts
. . . . . . . . .
Membership dues and assessments . . . . . . . . . . . . . . . . . . . .
Investment income . . . . . . . . . . . . . . . . . . . . . . . . .
Gross amount from sale of assets other than inventory
. . . .
5a
Less: cost or other basis and sales expenses . . . . . . . .
5b
Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) . . . .
Gaming and fundraising events
Gross income from gaming (attach Schedule G if greater than
$15,000) . . . . . . . . . . . . . . . . . . . .
6a
b Gross income from fundraising events (not including $
of contributions
from fundraising events reported on line 1) (attach Schedule G if the
sum of such gross income and contributions exceeds $15,000) . .
6b
c Less: direct expenses from gaming and fundraising events . . .
6c
d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract
line 6c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7a
b
c
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Gross sales of inventory, less returns and allowances . . . . .
7a
7b
Less: cost of goods sold
. . . . . . . . . . . . . .
Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) .
Other revenue (describe in Schedule O) . . . . . . . . . . . . .
Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 . . . . . . . .
Grants and similar amounts paid (list in Schedule O) . . . . . . . .
Benefits paid to or for members . . . . . . . . . . . . . . .
Salaries, other compensation, and employee benefits . . . . . . . .
Professional fees and other payments to independent contractors . . . .
Occupancy, rent, utilities, and maintenance . . . . . . . . . . .
Printing, publications, postage, and shipping . . . . . . . . . . .
Other expenses (describe in Schedule O) . . . . . . . . . . . .
Total expenses. Add lines 10 through 16 . . . . . . . . . . . .
Excess or (deficit) for the year (Subtract line 17 from line 9) . . . . . .
Net assets or fund balances at beginning of year (from line 27, column (A))
end-of-year figure reported on prior year’s return) . . . . . . . . .

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21

Other changes in net assets or fund balances (explain in Schedule O) . .
Net assets or fund balances at end of year. Combine lines 18 through 20

For Paperwork Reduction Act Notice, see the separate instructions.

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Cat. No. 10642I

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Form

990-EZ

(2011)

Form 990-EZ (2011)

Part II

Page

Check if the organization used Schedule O to respond to any question in this Part II . . . . . . . . . .
(A) Beginning of year

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25
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27

Cash, savings, and investments . . . . . . . . . . . . . . .
Land and buildings . . . . . . . . . . . . . . . . . . . .
Other assets (describe in Schedule O) . . . . . . . . . . . . .
Total assets . . . . . . . . . . . . . . . . . . . . . .
Total liabilities (describe in Schedule O) . . . . . . . . . . . .
Net assets or fund balances (line 27 of column (B) must agree with line 21)

Part III

2

Balance Sheets. (see the instructions for Part II.)

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Statement of Program Service Accomplishments (see the instructions for Part III.)
Check if the organization used Schedule O to respond to any question in this Part III

(B) End of year

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25
26
27
Expenses
(Required for section

. .

What is the organization’s primary exempt purpose?

501(c)(3) and 501(c)(4)
organizations and section
4947(a)(1) trusts; optional
for others.)

Describe the organization’s program service accomplishments for each of its three largest program services,
as measured by expenses. In a clear and concise manner, describe the services provided, the number of
persons benefited, and other relevant information for each program title.
28

(Grants $
29

(Grants $
30

) If this amount includes foreign grants, check here .

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28a

) If this amount includes foreign grants, check here .

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29a

(Grants $
) If this amount includes foreign grants, check here . . . . ▶
30a
31 Other program services (describe in Schedule O) . . . . . . . . . . . . . . . . . .
(Grants $
) If this amount includes foreign grants, check here . . . . ▶
31a
▶
32 Total program service expenses (add lines 28a through 31a) . . . . . . . . . . . . .
32
List of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated. (see the instructions for Part IV.)
Part IV

Check if the organization used Schedule O to respond to any question in this Part IV
(a) Name and title

(b) Average
hours per week
devoted to position

(c) Reportable
compensation
(Form W-2/1099-MISC)
(if not paid, enter -0-)

. . . . . . . . .

(d) Contributions to
employee benefit plans &
deferred compensation

(e) Estimated amount of
other compensation

Form

990-EZ

(2011)

Form 990-EZ (2011)

Part V

Page

Other Information (Note the Schedule A and personal benefit contract statement requirements in the

instructions for Part V.) Check if the organization used Schedule O to respond to any question in this Part V

3

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Yes No
33

Did the organization significantly engage in any activity not previously reported to the IRS? If “Yes,” provide a
detailed description of each activity in Schedule O . . . . . . . . . . . . . . . . . . .

34

Were any significant changes made to the organizing or governing documents? If “Yes,” attach a conformed
copy of the amended documents if they reflect a change to the organization's name. Otherwise, explain the
change on Schedule O (see instructions) . . . . . . . . . . . . . . . . . . . . . .
Did the organization have unrelated business gross income of $1,000 or more during the year from business
activities (such as those reported on lines 2, 6a, and 7a, among others)? . . . . . . . . . . . .

35a

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b If “Yes,” to line 35a, has the organization filed a Form 990-T for the year? If “No,” provide an explanation in Schedule O
c Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice,
reporting, and proxy tax requirements during the year? If “Yes,” complete Schedule C, Part III . . . . .
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets
during the year? If “Yes,” complete applicable parts of Schedule N
. . . . . . . . . . . . .
37a Enter amount of political expenditures, direct or indirect, as described in the instructions. ▶ 37a
b Did the organization file Form 1120-POL for this year? . . . . . . . . . . . . . . . . . .
38a Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return? .
b If “Yes,” complete Schedule L, Part II and enter the total amount involved . . . .
38b
39
Section 501(c)(7) organizations. Enter:
a Initiation fees and capital contributions included on line 9 . . . . . . . . . .
39a
b Gross receipts, included on line 9, for public use of club facilities . . . . . . .
39b
40a Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
; section 4912 ▶
; section 4955 ▶
section 4911 ▶
b Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefit
transaction during the year, or did it engage in an excess benefit transaction in a prior year that has not been
reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I . . . . . . .

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35a
35b
35c
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37b
38a

40b

c

Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on
organization managers or disqualified persons during the year under sections 4912,
4955, and 4958 . . . . . . . . . . . . . . . . . . . . . . . ▶
d Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c
reimbursed by the organization . . . . . . . . . . . . . . . . . ▶
e All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter
transaction? If “Yes,” complete Form 8886-T. . . . . . . . . . . . . . . . . . . . . .
List the states with which a copy of this return is filed. ▶
41
42a The organization's books are in care of ▶
Telephone no. ▶
Located at ▶
ZIP + 4 ▶
b At any time during the calendar year, did the organization have an interest in or a signature or other authority
over a financial account in a foreign country (such as a bank account, securities account, or other financial
account)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40e

Yes No
42b

If “Yes,” enter the name of the foreign country: ▶
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank
and Financial Accounts.
c
43

At any time during the calendar year, did the organization maintain an office outside the U.S.? . . . . .
42c
If “Yes,” enter the name of the foreign country: ▶
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041—Check here . . . . .
43
and enter the amount of tax-exempt interest received or accrued during the tax year . . . . . ▶

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Yes No
44a

Did the organization maintain any donor advised funds during the year? If “Yes,” Form 990 must be
completed instead of Form 990-EZ . . . . . . . . . . . . . . . . . . . . . . . .
b Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be
completed instead of Form 990-EZ . . . . . . . . . . . . . . . . . . . . . . . .
c Did the organization receive any payments for indoor tanning services during the year? . . . . . . .
d If "Yes" to line 44c, has the organization filed a Form 720 to report these payments? If "No," provide an
explanation in Schedule O . . . . . . . . . . . . . . . . . . . . . . . . . . .

44a
44b
44c
44d

Form

990-EZ

(2011)

Form 990-EZ (2011)

Page

4

Yes No
45a Did the organization have a controlled entity of the organization within the meaning of section 512(b)(13)? .
45b Did the organization receive any payment from or engage in any transaction with a controlled entity within the
meaning of section 512(b)(13)? If “Yes,” Form 990 and Schedule R may need to be completed instead of
Form 990-EZ (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition
46
to candidates for public office? If “Yes,” complete Schedule C, Part I . . . . . . . . . . . . .

Part VI

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45a

45b
46

Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only. All section
501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47–49b
and 52, and complete the tables for lines 50 and 51.
Check if the organization used Schedule O to respond to any question in this Part VI

. . . . . . . . .
Yes No

Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax
year? If “Yes,” complete Schedule C, Part II . . . . . . . . . . . . . . . . . . . . .

47
48
49a
b
50

47
Is the organization a school as described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E . . . .
48
Did the organization make any transfers to an exempt non-charitable related organization? . . . . . .
49a
If “Yes,” was the related organization a section 527 organization? . . . . . . . . . . . . . .
49b
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key
employees) who each received more than $100,000 of compensation from the organization. If there is none, enter “None.”
(a) Name and title of each employee
paid more than $100,000

e
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(b) Average
hours per week
devoted to position

(d) Estimated amount of other
compensation from the organization

Total number of other employees paid over $100,000 . . . . ▶
Complete this table for the organization's five highest compensated independent contractors who each received more than
$100,000 of compensation from the organization. If there is none, enter “None.”

(a) Name and address of each independent contractor paid more than $100,000

52

(c) Reportable compensation
from the organization
(Forms W-2/1099-MISC)

(b) Type of service

(d) Estimated amount of
other compensation

(c) Compensation

e Total number of other independent contractors each receiving over $100,000 . . ▶
Did the organization complete Schedule A? Note: All section 501(c)(3) organizations and 4947(a)(1)
nonexempt charitable trusts must attach a completed Schedule A . . . . . . . . . . . .

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Yes

▶

No

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Paid
Preparer
Use Only

▲ ▲

Sign
Here

Date

Signature of officer
Type or print name and title

Print/Type preparer’s name

Preparer's signature

Date

Check
if
self-employed

Firm’s name

▶

Firm's EIN

Firm's address

▶

Phone no.

May the IRS discuss this return with the preparer shown above? See instructions

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PTIN

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Yes

No

Form 990-EZ (2011)