Short Form Return of Organization Exempt From Income Tax

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Form

990-EZ

Short Form
Return of Organization Exempt From Income Tax

▶

Information about Form 990-EZ and its instructions is at www.irs.gov/form990.

DRAFT AS OF
May 20, 2014
DO NOT FILE
, 2014, and ending

Initial return

Final return/terminated
Amended return
Application pending

, 20
D Employer identification number

Room/suite

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

Name change

E Telephone number

City or town, state or province, country, and ZIP or foreign postal code

Cash
G Accounting Method:
I Website: ▶
J Tax-exempt status (check only one) —

Accrual

Other (specify)

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
K Form of organization:
Corporation
Trust
Association
Other
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, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ . . . . . . . . . .

Part I

Open to Public
Inspection

Do not enter social security numbers on this form as it may be made public.

A For the 2014 calendar year, or tax year beginning
C Name of organization
B Check if applicable:
Address change

2014

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-1150

▶

$

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

Net Assets

Expenses

Revenue

Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . . . .
1
2
3
4
5a
b
c
6
a

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
8
9
10
11
12
13
14
15
16
17
18
19

Gross sales of inventory, less returns and allowances . . . . .
7a
Less: cost of goods sold
. . . . . . . . . . . . . .
7b
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) . . . . . . . . .

20
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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5c

6d

7c
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Form

990-EZ

(2014)

Form 990-EZ (2014)

Part II

Page

2

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

22
23
24
25
26
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

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22
23
24
25
26
27

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DRAFT AS OF
May 20, 2014
DO NOT FILE

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

. .

What is the organization’s primary exempt purpose?

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

(B) End of year

(Grants $

Expenses
(Required for section

501(c)(3) and 501(c)(4)
organizations; optional for
others.)

) 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

30

(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
Part IV
List of Officers, Directors, Trustees, and Key Employees (list each one even if not compensated—see the instructions for 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
(d) Health benefits,
compensation
contributions to employee (e) Estimated amount of
other compensation
(Forms W-2/1099-MISC)
benefit plans, and
(if not paid, enter -0-) deferred compensation

Form

990-EZ

(2014)

Form 990-EZ (2014)

Part V

Page

3

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
Yes No

33

Did the organization engage in any significant 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

DRAFT AS OF
May 20, 2014
DO NOT FILE

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 4911 ▶
; section 4912 ▶
; section 4955 ▶
b Section 501(c)(3), 501(c)(4), and 501(c)(29) 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

33

34
35a
35b
35c
36
37b
38a

40b

c

Section 501(c)(3), 501(c)(4), and 501(c)(29) 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), 501(c)(4), and 501(c)(29) 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)?
If “Yes,” enter the name of the foreign country: ▶
See the instructions for exceptions and filing requirements for FinCEN Form 114, Report of Foreign Bank and
Financial Accounts (FBAR).
c
43

40e

Yes No
42b

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 . . . . .
and enter the amount of tax-exempt interest received or accrued during the tax year . . . . . ▶
43

.

▶

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 . . . . . . . . . . . . . . . . . . . . . . . . . . .

45a Did the organization have a controlled entity within the meaning of section 512(b)(13)? . . . . . . .
b 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) . . . . . . . . . . . . . . . . . . . . . . . . . .

44a
44b
44c
44d
45a

45b

Form

990-EZ

(2014)

Form 990-EZ (2014)

Page

4

Yes No
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition
to candidates for public office? If “Yes,” complete Schedule C, Part I . . . . . . . . . . . . .

46

Part VI

DRAFT AS OF
May 20, 2014
DO NOT FILE

Check if the organization used Schedule O to respond to any question in this Part VI
47

Yes No

47
Is the organization a school as described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E . . . .
48
49a
Did the organization make any transfers to an exempt non-charitable related organization? . . . . . .
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

(b) Average
hours per week
devoted to position

(d) Health benefits,
(c) Reportable
contributions to employee (e) Estimated amount of
compensation
other compensation
benefit plans, and deferred
(Forms W-2/1099-MISC)
compensation

f 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 business address of each independent contractor

52

. . . . . . . . .

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 . . . . . . . . . . . . . . . . . . . . .

48
49a
b
50

51

46

Section 501(c)(3) organizations only
All section 501(c)(3) organizations must answer questions 47–49b and 52, and complete the tables for lines
50 and 51.

(b) Type of service

(c) Compensation

d Total number of other independent contractors each receiving over $100,000 . . ▶
Did the organization complete Schedule A? Note. All section 501(c)(3) organizations must attach a
completed Schedule A . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 (2014)