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

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

2012

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
▶

Attach to Form 990 or Form 990-EZ.

▶ See

Open to Public
Inspection

separate instructions.

Name of the organization

Part I

OMB No. 1545-0047

Public Charity Status and Public Support

Employer identification number

DRAFT AS OF
July 3, 2012
DO NOT FILE
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.)
1
A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).
2
A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)
A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).
3
A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the
4
hospital’s name, city, and state:
5
An organization operated for the benefit of a college or university owned or operated by a governmental unit described in
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).
An organization that normally receives a substantial part of its support from a governmental unit or from the general public
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.)
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
Type I
b
Type II
c
Type III–Functionally integrated
d
Type III–Non-functionally integrated
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 III supporting
organization, check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?
Yes
No
(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? . . . . . . . . . . . . . .
11g(i)
(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

.
.

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

No

(A)
(B)
(C)
(D)
(E)
Total
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Schedule A (Form 990 or 990-EZ) 2012

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 or if the organization failed to qualify under
Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
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.") . . .

(a) 2008

(b) 2009

(c) 2010

(d) 2011

(e) 2012

(f) Total

(a) 2008

(b) 2009

(c) 2010

(d) 2011

(e) 2012

(f) Total

DRAFT AS OF
July 3, 2012
DO NOT FILE

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 .

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) . . . .

6

Public support. Subtract line 5 from line 4.

.

.

.

Section B. Total Support

Calendar year (or fiscal year beginning in) ▶
7
Amounts from line 4 . . . . . .
8
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

Other income. Do not include gain or
loss from the sale of capital assets
(Explain in Part IV.) . . . . . . .

11
12
13

Total support. Add lines 7 through 10
Gross receipts from related activities, etc. (see instructions) . . . . . . . . . . . .
12
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
15
16a

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) . . . .
14
15
Public support percentage from 2011 Schedule A, Part II, line 14 . . . . . . . . . .
331/3% support test—2012. 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 . . . . . . . . . . .
1
1
b 33 /3% support test—2011. If the organization did not check a box on line 13 or 16a, and line 15 is 33 /3% or more,
▶
check this box and stop here. The organization qualifies as a publicly supported organization
. . . . . . .

17a

%
%

10%-facts-and-circumstances test—2012. 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—2011. 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) 2012

Page 3

Schedule A (Form 990 or 990-EZ) 2012

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 or if the organization failed to qualify under Part II.
If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) ▶
Gifts, grants, contributions, and membership fees
1
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

(a) 2008

(b) 2009

(c) 2010

(d) 2011

(e) 2012

(f) Total

(a) 2008

(b) 2009

(c) 2010

(d) 2011

(e) 2012

(f) Total

DRAFT AS OF
July 3, 2012
DO NOT FILE

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
7a

Total. Add lines 1 through 5 . . . .
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
8

Add lines 7a and 7b . . . . . .
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
11

12

13
14

Add lines 10a and 10b . . . . .
Net income from unrelated business
activities not included in line 10b, whether
or not the business is regularly carried on
Other income. Do not include gain or
loss from the sale of capital assets
(Explain in Part IV.) . . . . . . .
Total support. (Add lines 9, 10c, 11,
and 12.) . . . . . . . . . .
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 2012 (line 8, column (f) divided by line 13, column (f))
Public support percentage from 2011 Schedule A, Part III, line 15 . . . . . .

.
.

.
.

.
.

.
.

.
.

15
16

%
%

Section D. Computation of Investment Income Percentage
17
18
19a

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) . . .
17
%
Investment income percentage from 2011 Schedule A, Part III, line 17 . . . . . . . . . .
18
%
331/3% support tests—2012. 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—2011. 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 ▶
Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ▶
20
Schedule A (Form 990 or 990-EZ) 2012

Page 4

Schedule A (Form 990 or 990-EZ) 2012

Part IV

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. Also complete this part for any additional information. (See
instructions).

DRAFT AS OF
July 3, 2012
DO NOT FILE

Schedule A (Form 990 or 990-EZ) 2012