Form Schedule A (Form 9 Schedule A (Form 9 Public Charity Status and Public Support

SCHEDULE A
(Form 990 or 990-EZ)

OMB No. 1545-0047

Public Charity Status and Public Support

2009

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Department of the Treasury
Internal Revenue Service

© Attach

to Form 990 or Form 990-EZ.

© See

separate instructions.

Name of the organization

Part I

Open to Public
Inspection

Employer identification number

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).
1
A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)
2
A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).
3
4
A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the
hospital’s name, city, and state:
An organization operated for the benefit of a college or university owned or operated by a governmental unit described in
5
section 170(b)(1)(A)(iv). (Complete Part II.)
A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).
6
An organization that normally receives a substantial part of its support from a governmental unit or from the general public
7
described in section 170(b)(1)(A)(vi). (Complete Part II.)
A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)
8
9
An organization that normally receives: (1) more than 331⁄ 3 % of its support from contributions, membership fees, and gross
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331⁄ 3 % of its
support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11

e

f
g

h

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).
An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the
purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section
509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.
a
b
c
d
Type I
Type II
Type III–Functionally integrated
Type III–Other
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified
persons other than foundation managers and other than one or more publicly supported organizations described in section
509(a)(1) or section 509(a)(2).
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type
organization, check this box
Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
and (iii) below, the governing body of the supported organization?
(ii) A family member of a person described in (i) above?
(iii) A 35% controlled entity of a person described in (i) or (ii) above?
Provide the following information about the supported organization(s).

(i) Name of supported
organization

(ii) EIN

(iii) Type of organization
(described on lines 1–9
above or IRC section
(see instructions))

(iv) Is the organization
in col. (i) listed in your
governing document?

Yes

No

(v) Did you notify
the organization in
col. (i) of your
support?

Yes

No

(vi) Is the
organization in col.
(i) organized in the
U.S.?

Yes

III supporting

Yes

No

11g(i)
11g(ii)
11g(iii)
(vii) Amount of
support

No

Total
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2009

Schedule A (Form 990 or 990-EZ) 2009

Page

2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I.)
Section A. Public Support
Calendar year (or fiscal year beginning in)

©

1

Gifts, grants, contributions, and
membership fees received. (Do not
include any "unusual grants.")

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
Total. Add lines 1 through 3
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)
Public support. Subtract line 5 from line 4.

4
5

6

(a) 2005

(b) 2006

(c) 2007

(d) 2008

(e) 2009

(f) Total

(a) 2005

(b) 2006

(c) 2007

(d) 2008

(e) 2009

(f) Total

Section B. Total Support
Calendar year (or fiscal year beginning in)

©

7
8

Amounts from line 4
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

11
12
13

Other income. Do not include gain or
loss from the sale of capital assets
(Explain in Part IV.)
Total support. Add lines 7 through 10
12
Gross receipts from related activities, etc. (see instructions)
First five years. If the Form 990 is for the organization’s first, second, third, fourth, or fifth tax year as a section 501(c)(3)
©
organization, check this box and stop here

Section C. Computation of Public Support Percentage
14

Public support percentage for 2009 (line 6, column (f) divided by line 11, column (f))

14

%

%
15
15 Public support percentage from 2008 Schedule A, Part II, line 14
16a 331⁄ 3 % support test—2009. If the organization did not check the box on line 13, and line 14 is 331⁄ 3 % or more, check this box
©
and stop here. The organization qualifies as a publicly supported organization
b 331⁄ 3 % support test—2008. If the organization did not check a box on line 13 or 16a, and line 15 is 331⁄ 3 % or more, check this
©
box and stop here. The organization qualifies as a publicly supported organization
17a 10%-facts-and-circumstances test—2009. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or
more, and if the organization meets the “facts-and-circumstances” test, check this box and stop here. Explain in Part IV how the
©
organization meets the “facts-and-circumstances” test. The organization qualifies as a publicly supported organization
b 10%-facts-and-circumstances test—2008. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or
more, and if the organization meets the “facts-and-circumstances” test, check this box and stop here. Explain in Part IV how the
©
organization meets the “facts-and-circumstances” test. The organization qualifies as a publicly supported organization
18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions ©
Schedule A (Form 990 or 990-EZ) 2009

Schedule A (Form 990 or 990-EZ) 2009

Page

3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
1

2

©

(b) 2006

(c) 2007

(d) 2008

(e) 2009

(f) Total

(a) 2005

(b) 2006

(c) 2007

(d) 2008

(e) 2009

(f) Total

Gifts,
grants,
contributions,
and
membership fees received. (Do not include
any "unusual grants.")
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
Total. Add lines 1 through 5

6

(a) 2005

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.)

Section B. Total Support
Calendar year (or fiscal year beginning in)

©

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 IV.)

13

Total support. (Add lines 9, 10c, 11,
and 12.)

14

First five years. If the Form 990 is for the organization’s first, second, third, fourth, or fifth tax year as a section 501(c)(3)
©
organization, check this box and stop here

Section C. Computation of Public Support Percentage
15
16

Public support percentage for 2009 (line 8, column (f) divided by line 13, column (f))
Public support percentage from 2008 Schedule A, Part III, line 15

15
16

%
%

Section D. Computation of Investment Income Percentage
%
17
17 Investment income percentage for 2009 (line 10c, column (f) divided by line 13, column (f))
%
18
18 Investment income percentage from 2008 Schedule A, Part III, line 17
19a 331⁄ 3 % support tests—2009. If the organization did not check the box on line 14, and line 15 is more than 331⁄ 3 %, and line

17 is not more than 331⁄ 3 %, check this box and stop here. The organization qualifies as a publicly supported organization ©
b 331⁄ 3 % support tests—2008. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 331⁄ 3 %, and
line 18 is not more than 331⁄ 3 %, check this box and stop here. The organization qualifies as a publicly supported organization ©
20 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ©
Schedule A (Form 990 or 990-EZ) 2009

Schedule A (Form 990 or 990-EZ) 2009

Part IV

Page

4

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10;
Part II, line 17a or 17b; and Part III, line 12. Provide any other additional information. See instructions.

Schedule A (Form 990 or 990-EZ) 2009