Form 990 Return of Organization Exempt From Income Tax Under Sect

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Form

990

OMB No. 1545-0047

Return of Organization Exempt From Income Tax

2012

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung
benefit trust or private foundation)

Department of the Treasury
Internal Revenue Service

▶

Open to Public
Inspection

The organization may have to use a copy of this return to satisfy state reporting requirements.

A

For the 2012 calendar year, or tax year beginning

B

Check if applicable: C Name of organization

, 2012, and ending

, 20

DRAFT AS OF
July 6, 2012
DO NOT FILE

D Employer identification number

Address change

Doing Business As

Name change

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

E Telephone number

Room/suite

Initial return

City, town or post office, state, and ZIP code

Terminated

G Gross receipts $

Amended return

Application pending F Name and address of principal officer:

H(a) Is this a group return for affiliates?

I

Tax-exempt status:

H(b) Are all affiliates included?
Yes
No
If “No,” attach a list. (see instructions)

J
K

Website:

Net Assets or
Fund Balances

Expenses

Revenue

Activities & Governance

1

2
3
4
5
6
7a
b
8
9
10
11
12
13
14
15
16a
b
17
18
19
20
21
22

) ◀ (insert no.)

501(c) (

4947(a)(1) or

527

H(c) Group exemption number

Form of organization:

Part I

501(c)(3)

▶

Corporation

Trust

Association

Other

L Year of formation:

▶

Yes

No

▶

M State of legal domicile:

Summary

Briefly describe the organization’s mission or most significant activities:

Check this box ▶ if the organization discontinued its operations or disposed of more than 25% of its net assets.
3
Number of voting members of the governing body (Part VI, line 1a) . . . . . . . . .
Number of independent voting members of the governing body (Part VI, line 1b) . . . .
4
Total number of individuals employed in calendar year 2012 (Part V, line 2a)
. . . . .
5
Total number of volunteers (estimate if necessary) . . . . . . . . . . . . . .
6
Total unrelated business revenue from Part VIII, column (C), line 12 . . . . . . . .
7a
Net unrelated business taxable income from Form 990-T, line 34 . . . . . . . . .
7b
Prior Year

Current Year

Beginning of Current Year

End of Year

Contributions and grants (Part VIII, line 1h) . . . . . . . . . . . .
Program service revenue (Part VIII, line 2g)
. . . . . . . . . . .
Investment income (Part VIII, column (A), lines 3, 4, and 7d) . . . . . .
Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) . . .
Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)
Grants and similar amounts paid (Part IX, column (A), lines 1–3) . . . . .
Benefits paid to or for members (Part IX, column (A), line 4) . . . . . .
Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)
Professional fundraising fees (Part IX, column (A), line 11e) . . . . . .
Total fundraising expenses (Part IX, column (D), line 25) ▶
Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)
. . . . .
Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)
.
Revenue less expenses. Subtract line 18 from line 12 . . . . . . . .
Total assets (Part X, line 16) . . . . . . . . . .
Total liabilities (Part X, line 26) . . . . . . . . . .
Net assets or fund balances. Subtract line 21 from line 20

Part II

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Signature Block

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.

▲▲

Sign
Here

Paid
Preparer
Use Only

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) .
For Paperwork Reduction Act Notice, see the separate instructions.

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Cat. No. 11282Y

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PTIN

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Yes

No

Form 990 (2012)

Page 2

Form 990 (2012)

Part III

Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . . . . . .

1

Briefly describe the organization’s mission:

2

Did the organization undertake any significant program services during the year which were not listed on the
prior Form 990 or 990-EZ? . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

DRAFT AS OF
July 6, 2012
DO NOT FILE
Yes

No

If “Yes,” describe these new services on Schedule O.
Did the organization cease conducting, or make significant changes in how it conducts, any program
services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

Yes
No
If “Yes,” describe these changes on Schedule O.
Describe the organization's program service accomplishments for each of its three largest program services, as measured by
expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others,
the total expenses, and revenue, if any, for each program service reported.

4a

(Code:

) (Expenses $

including grants of $

) (Revenue $

)

4b (Code:

) (Expenses $

including grants of $

) (Revenue $

)

4c

) (Expenses $

including grants of $

) (Revenue $

)

(Code:

4d Other program services (Describe in Schedule O.)
(Expenses $
including grants of $
4e Total program service expenses ▶

) (Revenue $

)
Form 990 (2012)

Page 3

Form 990 (2012)

Part IV

Checklist of Required Schedules
Yes

1

Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,”
complete Schedule A . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2
3

Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? . . .
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to
candidates for public office? If “Yes,” complete Schedule C, Part I . . . . . . . . . . . . . .
Section 501(c)(3) organizations. 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 . . . . . . . . . . .

No

1
2

DRAFT AS OF
July 6, 2012
DO NOT FILE

4
5

Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues,
assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

Did the organization maintain any donor advised funds or any similar funds or accounts for which donors
have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If
“Yes,” complete Schedule D, Part I . . . . . . . . . . . . . . . . . . . . . . . .
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part II
. . .
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,”
complete Schedule D, Part III . . . . . . . . . . . . . . . . . . . . . . . . . .

7
8
9

Did the organization report an amount in Part X, line 21, for escrow or custodial account liability; serve as a
custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or
debt negotiation services? If “Yes,” complete Schedule D, Part IV . . . . . . . . . . . . . .

10

Did the organization, directly or through a related organization, hold assets in temporarily restricted
endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part V . .
If the organization’s answer to any of the following questions is “Yes,” then complete Schedule D, Parts VI,
VII, VIII, IX, or X as applicable.
Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If “Yes,”
complete Schedule D, Part VI . . . . . . . . . . . . . . . . . . . . . . . . . .
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more
of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII . . . . . . . .
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more
of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII . . . . . . . .
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets
reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX . . . . . . . . . . . . . .

11
a
b
c
d

e Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X
f Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses
the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X .
12 a Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete
Schedule D, Parts XI and XII

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b Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if
the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional . . . . . . .
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E . . . .
14 a Did the organization maintain an office, employees, or agents outside of the United States? . . . . .
b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking,
fundraising, business, investment, and program service activities outside the United States, or aggregate
foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV . . . . .
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any
organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV . .
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance
to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV . . . .
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on
Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions) . . . . .
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on
Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II . . . . . . . . . . . . . . .
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a?
If “Yes,” complete Schedule G, Part III . . . . . . . . . . . . . . . . . . . . . . .
20 a Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H . . . . . .
b If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return?
.

3
4

5

6
7
8

9

10

11a
11b
11c
11d
11e
11f
12a
12b
13
14a

14b
15
16
17
18
19
20a
20b
Form 990 (2012)

Page 4

Form 990 (2012)

Part IV

Checklist of Required Schedules (continued)
Yes

21

Did the organization report more than $5,000 of grants and other assistance to any government or organization
in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II . . . . .
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States
on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III . . . . . . . . . . . .

22

Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the
organization’s current and former officers, directors, trustees, key employees, and highest compensated
employees? If “Yes,” complete Schedule J . . . . . . . . . . . . . . . . . . . . . .

24a

Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than
$100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b
through 24d and complete Schedule K. If “No,” go to line 25 . . . . . . . . . . . . . . . .

b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? . .
c Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds? . . . . . . . . . . . . . . . . . . . . . . . .

d Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year? . .
25a Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction
with a disqualified person during the year? If “Yes,” complete Schedule L, Part I . . . . . . . . .

b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior
year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ?
If “Yes,” complete Schedule L, Part I . . . . . . . . . . . . . . . . . . . . . . . .
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or
disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L, Part II . .
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee,
substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled
entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III . . . . . . .
Was the organization a party to a business transaction with one of the following parties (see Schedule L,
Part IV instructions for applicable filing thresholds, conditions, and exceptions):

28

a A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV . .
b A family member of a current or former officer, director, trustee, or key employee? If “Yes,” complete
Schedule L, Part IV
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof)
was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV . . .
29
30
31
32
33
34

Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified
conservation contributions? If “Yes,” complete Schedule M . . . . . . . . . . . . . . . .
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,”
complete Schedule N, Part II . . . . . . . . . . . . . . . . . . . . . . . . . .
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations
sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I . . . . . . . . . . .
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III,
or IV, and Part V, line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35a Did the organization have a controlled entity within the meaning of section 512(b)(13)? . . . . . . .
b If "Yes" to line 35a, 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,” complete Schedule R, Part V, line 2 . .
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable
related organization? If “Yes,” complete Schedule R, Part V, line 2 . . . . . . . . . . . . . .
37

38

21

DRAFT AS OF
July 6, 2012
DO NOT FILE

23

27

No

Did the organization conduct more than 5% of its activities through an entity that is not a related organization
and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R,
Part VI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and
19? Note. All Form 990 filers are required to complete Schedule O . . . . . . . . . . . . . .

22

23

24a
24b
24c
24d
25a

25b
26

27

28a
28b
28c
29
30
31
32
33
34
35a
35b
36

37
38

Form 990 (2012)

Page 5

Form 990 (2012)

Part V

Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V

. . . . . . . . . . . . . .
Yes

1a Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable
. . . .
1a
b Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable . . . .
1b
c Did the organization comply with backup withholding rules for reportable payments to vendors and
reportable gaming (gambling) winnings to prize winners? . . . . . . . . . . . . . . . . .
2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax
Statements, filed for the calendar year ending with or within the year covered by this return
2a
b If at least one is reported on line 2a, did the organization file all required federal employment tax returns? .
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions) . .
3a Did the organization have unrelated business gross income of $1,000 or more during the year? . . . .
b If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O . . . . .
4a 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)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No

DRAFT AS OF
July 6, 2012
DO NOT FILE

b If “Yes,” enter the name of the foreign country: ▶
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? . . .
b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
c If “Yes” to line 5a or 5b, did the organization file Form 8886-T? . . . . . . . . . . . . . . .
6a Does the organization have annual gross receipts that are normally greater than $100,000, and did the
organization solicit any contributions that were not tax deductible as charitable contributions? . . . . .
b If “Yes,” did the organization include with every solicitation an express statement that such contributions or
gifts were not tax deductible? . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Organizations that may receive deductible contributions under section 170(c).
a Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods
and services provided to the payor? . . . . . . . . . . . . . . . . . . . . . . . .
b If “Yes,” did the organization notify the donor of the value of the goods or services provided? . . . . .
c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was
required to file Form 8282? . . . . . . . . . . . . . . . . . . . . . . . . . . .
d
e
f
g
h
8

9
a
b
10
a
b
11
a
b
12a
b
13
a
b

If “Yes,” indicate the number of Forms 8282 filed during the year . . . . . . . .
7d
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? .
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting
organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring
organization, have excess business holdings at any time during the year? . . . . . . . . . . .
Sponsoring organizations maintaining donor advised funds.
Did the organization make any taxable distributions under section 4966? . . . . . . . . . . . .
Did the organization make a distribution to a donor, donor advisor, or related person? . . . . . . .
Section 501(c)(7) organizations. Enter:
Initiation fees and capital contributions included on Part VIII, line 12 . . . . . . .
10a
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities .
10b
Section 501(c)(12) organizations. Enter:
11a
Gross income from members or shareholders . . . . . . . . . . . . . . .
Gross income from other sources (Do not net amounts due or paid to other sources
against amounts due or received from them.) . . . . . . . . . . . . . . .
11b
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year . .
12b
Section 501(c)(29) qualified nonprofit health insurance issuers.
Is the organization licensed to issue qualified health plans in more than one state?
. . . . . . . .
Note. See the instructions for additional information the organization must report on Schedule O.
Enter the amount of reserves the organization is required to maintain by the states in which
the organization is licensed to issue qualified health plans
. . . . . . . . . .
13b

c Enter the amount of reserves on hand . . . . . . . . . . . . . . . . .
13c
14a Did the organization receive any payments for indoor tanning services during the tax year? . . . . .
b If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O

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1c

2b
3a
3b

4a

5a
5b
5c
6a

6b

7a
7b
7c
7e
7f
7g
7h

8
9a
9b

12a

13a

14a
14b

Form 990 (2012)

Page 6
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No”
response to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.

Form 990 (2012)

Part VI

Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . . . . . .

Section A. Governing Body and Management
Yes

1a

DRAFT AS OF
July 6, 2012
DO NOT FILE

Enter the number of voting members of the governing body at the end of the tax year . .
If there are material differences in voting rights among members of the governing body, or
if the governing body delegated broad authority to an executive committee or similar
committee, explain in Schedule O.

1a

b Enter the number of voting members included in line 1a, above, who are independent .
1b
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with
any other officer, director, trustee, or key employee? . . . . . . . . . . . . . . . . . .
3
Did the organization delegate control over management duties customarily performed by or under the direct
supervision of officers, directors, or trustees, or key employees to a management company or other person?
.
4
5
6
7a

No

Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
Did the organization have members or stockholders? . . . . . . . . . . . . . . . . . .
Did the organization have members, stockholders, or other persons who had the power to elect or appoint
one or more members of the governing body? . . . . . . . . . . . . . . . . . . . .
b Are any governance decisions of the organization reserved to (or subject to approval by) members,
stockholders, or persons other than the governing body? . . . . . . . . . . . . . . . . .
8
Did the organization contemporaneously document the meetings held or written actions undertaken during
the year by the following:
a The governing body? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b Each committee with authority to act on behalf of the governing body? . . . . . . . . . . . .
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at
the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O . . . . .

2
3
4
5
6

7a

7b

8a
8b
9

Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes

10a Did the organization have local chapters, branches, or affiliates?
. . . . . . . . . . . . . .
b If “Yes,” did the organization have written policies and procedures governing the activities of such chapters,
affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
11a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
b Describe in Schedule O the process, if any, used by the organization to review this Form 990.
12a Did the organization have a written conflict of interest policy? If “No,” go to line 13
. . . . . . . .
b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts?
c Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,”
describe in Schedule O how this was done . . . . . . . . . . . . . . . . . . . . . .
13
Did the organization have a written whistleblower policy? . . . . . . . . . . . . . . . . .
14
Did the organization have a written document retention and destruction policy?
. . . . . . . . .
15
Did the process for determining compensation of the following persons include a review and approval by
independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a The organization’s CEO, Executive Director, or top management official . . . . . . . .
b Other officers or key employees of the organization . . . . . . . . . . . . . . .
If “Yes” to line 15a or 15b, describe the process in Schedule O (see instructions).
16a Did the organization invest in, contribute assets to, or participate in a joint venture or similar
with a taxable entity during the year? . . . . . . . . . . . . . . . . . . . .

.
.

.
.

.
.

.
.

No

10a
10b
11a
12a
12b
12c
13
14

15a
15b

arrangement
. . . .

16a

b If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its
participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the
organization’s exempt status with respect to such arrangements? . . . . . . . . . . . . . .

16b

Section C. Disclosure
17
18

19
20

List the states with which a copy of this Form 990 is required to be filed ▶
Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (Section 501(c)(3)s only)
available for public inspection. Indicate how you made these available. Check all that apply.
Own website
Another’s website
Upon request
Other (explain in Schedule O)
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy,
and financial statements available to the public during the tax year.
State the name, physical address, and telephone number of the person who possesses the books and records of the
organization: ▶
Form 990 (2012)

Page 7
Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and
Independent Contractors

Form 990 (2012)

Part VII

Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the
organization’s tax year.
• List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount of
compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

DRAFT AS OF
July 6, 2012
DO NOT FILE

• List all of the organization’s current key employees, if any. See instructions for definition of “key employee.”
• List the organization’s five current highest compensated employees (other than an officer, director, trustee, or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.
• List all of the organization’s former officers, key employees, and highest compensated employees who received more than
$100,000 of reportable compensation from the organization and any related organizations.
• List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.
List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(C)

Former

Highest compensated
employee

Key employee

Average
hours per
week (list any
hours for
related
organizations
below dotted
line)

Officer

Name and Title

Position
(do not check more than one
box, unless person is both an
officer and a director/trustee)
Institutional trustee

(B)

Individual trustee
or director

(A)

(D)

(E)

Reportable
Reportable
compensation compensation from
from
related
the
organizations
organization
(W-2/1099-MISC)
(W-2/1099-MISC)

(F)

Estimated
amount of
other
compensation
from the
organization
and related
organizations

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
Form 990 (2012)

Page 8

Form 990 (2012)

Part VII

Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(C)

(21)

Former

(20)

Highest compensated
employee

(19)

Key employee

(18)

Officer

(17)

(D)

(E)

(F)

Reportable
Reportable
compensation compensation from
from
related
the
organizations
organization
(W-2/1099-MISC)
(W-2/1099-MISC)

Estimated
amount of
other
compensation
from the
organization
and related
organizations

DRAFT AS OF
July 6, 2012
DO NOT FILE
Institutional trustee

(16)

(B)
Average
hours per
week (list any
hours for
related
organizations
below dotted
line)

Individual trustee
or director

(15)

(A)
Name and title

Position
(do not check more than one
box, unless person is both an
officer and a director/trustee)

(22)
(23)
(24)
(25)
1b
c
d
2

Sub-total . . . . . . . . . . . . . . . . . . . . . ▶
Total from continuation sheets to Part VII, Section A . . . . . ▶
Total (add lines 1b and 1c) . . . . . . . . . . . . . . . ▶
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of
reportable compensation from the organization ▶

3

Did the organization list any former officer, director, or trustee, key employee, or highest compensated
employee on line 1a? If “Yes,” complete Schedule J for such individual . . . . . . . . . . . .

4

For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the
organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such
individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual
for services rendered to the organization? If “Yes,” complete Schedule J for such person . . . . . .

Yes No

5

3

4

5
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of
compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax
year.
(A)
Name and business address

2

(B)
Description of services

(C)
Compensation

Total number of independent contractors (including but not limited to those listed above) who
received more than $100,000 of compensation from the organization ▶
Form 990 (2012)

Page 9

Form 990 (2012)

Part VIII Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII. .

Program Service Revenue

Contributions, Gifts, Grants
and Other Similar Amounts

(A)
Total revenue

(C)
Unrelated
business
revenue

(D)
Revenue
excluded from tax
under sections
512, 513, or 514

DRAFT AS OF
July 6, 2012
DO NOT FILE

1a
b
c
d
e
f

1a
1b
1c
1d
1e

Federated campaigns . . .
Membership dues . . . .
Fundraising events . . . .
Related organizations . . .
Government grants (contributions)
All other contributions, gifts, grants,
and similar amounts not included above

1f
g Noncash contributions included in lines 1a-1f: $
h Total. Add lines 1a–1f . . . . . .

.

.

.

▶

Business Code

2a
b
c
d
e
f All other program service revenue .
g Total. Add lines 2a–2f . . . . . . . . . ▶
3
Investment income (including dividends, interest,
and other similar amounts) . . . . . . . ▶
4
5

Income from investment of tax-exempt bond proceeds ▶
Royalties . . . . . . . . . . . . . ▶
(i) Real

(ii) Personal

6a
b
c
d
7a

Gross rents . .
Less: rental expenses
Rental income or (loss)
Net rental income or (loss) . . .
(i) Securities
Gross amount from sales of
assets other than inventory
b Less: cost or other basis
and sales expenses .
c Gain or (loss) . .
d Net gain or (loss)

Other Revenue

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

(B)
Related or
exempt
function
revenue

8a

b
c
9a
b
c
10a
b
c

.

.

.

.

.

.

.

.

.

.

.

.

Gross income from fundraising
events (not including $
of contributions reported on line 1c).
See Part IV, line 18 . . . . . a
Less: direct expenses . . . . b
Net income or (loss) from fundraising events
Gross income from gaming activities.
See Part IV, line 19 . . . . . a
Less: direct expenses . . . . b
Net income or (loss) from gaming activities .
Gross sales of inventory, less
returns and allowances . . . a
Less: cost of goods sold . . . b
Net income or (loss) from sales of inventory .

▶

.

▶

.

▶

.

▶

.

▶

Business Code

Miscellaneous Revenue

11a
b
c
d All other revenue . . . . .
e Total. Add lines 11a–11d . . .
12
Total revenue. See instructions.

.

(ii) Other

.
.

.
.

.
.

.
.

.
.

▶
▶
Form 990 (2012)

Page 10

Form 990 (2012)

Part IX

Statement of Functional Expenses

Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).

Check if Schedule O contains a response to any question in this Part IX . . . . . . . . . . . . . .
Do not include amounts reported on lines 6b, 7b,
8b, 9b, and 10b of Part VIII.
1
2

(B)
Program service
expenses

(C)
Management and
general expenses

(D)
Fundraising
expenses

DRAFT AS OF
July 6, 2012
DO NOT FILE

Grants and other assistance to governments and
organizations in the United States. See Part IV, line 21
Grants and other assistance to individuals in
the United States. See Part IV, line 22 . . .

3

Grants and other assistance to governments,
organizations, and individuals outside the
United States. See Part IV, lines 15 and 16 . .

4
5

Benefits paid to or for members . . . .
Compensation of current officers, directors,
trustees, and key employees . . . . .

6

Compensation not included above, to disqualified
persons (as defined under section 4958(f)(1)) and
persons described in section 4958(c)(3)(B) . .

7
8

Other salaries and wages . . . . . .
Pension plan accruals and contributions (include
section 401(k) and 403(b) employer contributions)

9
10
11

(A)
Total expenses

Other employee benefits . . . . . . .
Payroll taxes . . . . . . . . . . .
Fees for services (non-employees):
a Management
. . . . . . . . . .
b Legal . . . . . . . . . . . . .
c Accounting . . . . . . . . . . .
d Lobbying . . . . . . . . . . . .
e Professional fundraising services. See Part IV, line 17
f Investment management fees . . . . .
Other. (If line 11g amount exceeds 10% of line 25, column
g
(A) amount, list line 11g expenses on Schedule O.) . .

12
13
14
15
16
17
18

Advertising and promotion . . . . . .
Office expenses
. . . . . . . . .
Information technology . . . . . . .
Royalties . . . . . . . . . . . .
Occupancy . . . . . . . . . . .
Travel . . . . . . . . . . . . .
Payments of travel or entertainment expenses
for any federal, state, or local public officials

19
20
21
22
23
24

Conferences, conventions, and meetings .
Interest . . . . . . . . . . . .
Payments to affiliates . . . . . . . .
Depreciation, depletion, and amortization .
Insurance . . . . . . . . . . . .
Other expenses. Itemize expenses not covered
above (List miscellaneous expenses in line 24e. If
line 24e amount exceeds 10% of line 25, column
(A) amount, list line 24e expenses on Schedule O.)

a
b
c
d
e All other expenses
Total functional expenses. Add lines 1 through 24e
25
Joint costs. Complete this line only if the
26
organization reported in column (B) joint costs
from a combined educational campaign and
fundraising solicitation. Check here ▶
if
following SOP 98-2 (ASC 958-720)
. . . .
Form 990 (2012)

Page 11

Form 990 (2012)

Part X

Balance Sheet
Check if Schedule O contains a response to any question in this Part X

. . . . . . . . . . . . . .
(A)
Beginning of year

1
2
3
4
5

Net Assets or Fund Balances

Liabilities

Assets

6

Cash—non-interest-bearing . . . . . . . . . . . . . .
Savings and temporary cash investments . . . . . . . . . .
Pledges and grants receivable, net . . . . . . . . . . . .
Accounts receivable, net
. . . . . . . . . . . . . . .
Loans and other receivables from current and former officers, directors,
trustees, key employees, and highest compensated employees.
Complete Part II of Schedule L . . . . . . . . . . . . .

b
11
12
13
14
15
16
17
18
19
20
21
22

Loans and other receivables from other disqualified persons (as defined under section
4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and
sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary
organizations (see instructions). Complete Part II of Schedule L. . . . . . . .
Notes and loans receivable, net . . . . .
Inventories for sale or use . . . . . . .
Prepaid expenses and deferred charges . .
Land, buildings, and equipment: cost or
other basis. Complete Part VI of Schedule D

.
.
.

.
.
.

.
.
.

.
.
.

.
.
.

.
.
.

.
.
.

.
.
.

10a
Less: accumulated depreciation . . . .
10b
Investments—publicly traded securities
. . . . . . . . . .
Investments—other securities. See Part IV, line 11 . . . . . . .
Investments—program-related. See Part IV, line 11 . . . . . . .
Intangible assets . . . . . . . . . . . . . . . . . .
Other assets. See Part IV, line 11 . . . . . . . . . . . . .
Total assets. Add lines 1 through 15 (must equal line 34) . . . . .
Accounts payable and accrued expenses . . . . . . . . . .
Grants payable . . . . . . . . . . . . . . . . . . .
Deferred revenue . . . . . . . . . . . . . . . . . .
Tax-exempt bond liabilities . . . . . . . . . . . . . . .
Escrow or custodial account liability. Complete Part IV of Schedule D .
Loans and other payables to current and former officers, directors,
trustees, key employees, highest compensated employees, and
disqualified persons. Complete Part II of Schedule L . . . . . .

23
24
25

Secured mortgages and notes payable to unrelated third parties . .
Unsecured notes and loans payable to unrelated third parties . . .
Other liabilities (including federal income tax, payables to related third
parties, and other liabilities not included on lines 17-24). Complete Part X
of Schedule D . . . . . . . . . . . . . . . . . . .

26

Total liabilities. Add lines 17 through 25 . . . . . . . .
Organizations that follow SFAS 117 (ASC 958), check here ▶
complete lines 27 through 29, and lines 33 and 34.

.

Unrestricted net assets . . . . . . . . . . . . . .
Temporarily restricted net assets . . . . . . . . . . .
Permanently restricted net assets . . . . . . . . . . .
Organizations that do not follow SFAS 117 (ASC 958), check here ▶
complete lines 30 through 34.

.
.
.

30
31
32
33
34

1
2
3
4

DRAFT AS OF
July 6, 2012
DO NOT FILE

7
8
9
10a

27
28
29

(B)
End of year

.

5

6
7
8
9

10c
11
12
13
14
15
16
17
18
19
20
21

22
23
24

25
26

and

Capital stock or trust principal, or current funds . . . . . . .
Paid-in or capital surplus, or land, building, or equipment fund . .
Retained earnings, endowment, accumulated income, or other funds
Total net assets or fund balances . . . . . . . . . . . .
Total liabilities and net assets/fund balances . . . . . . . .

27
28
29

.
.
.
and
.
.
.
.
.

30
31
32
33
34

Form 990 (2012)

Page 12

Form 990 (2012)

Part XI

Reconciliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . . . . . .

1
2
3
4
5
6
7
8
9
10

Total revenue (must equal Part VIII, column (A), line 12) . . . . . . . . . . . .
Total expenses (must equal Part IX, column (A), line 25)
. . . . . . . . . . .
Revenue less expenses. Subtract line 2 from line 1 . . . . . . . . . . . . .
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) .
Net unrealized gains (losses) on investments . . . . . . . . . . . . . . .
Donated services and use of facilities
. . . . . . . . . . . . . . . . .
Investment expenses . . . . . . . . . . . . . . . . . . . . . . .
Prior period adjustments . . . . . . . . . . . . . . . . . . . . . .
Other changes in net assets or fund balances (explain in Schedule O) . . . . . . .
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part
33, column (B)) . . . . . . . . . . . . . . . . . . . . . . . . .

.
.
.
.
.
.
.
.
.
X,
.

.
.
.
.
.
.
.
.
.
line
.

1
2
3
4
5
6
7
8
9

DRAFT AS OF
July 6, 2012
DO NOT FILE

Part XII

10

Financial Statements and Reporting

Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . . . . . .
Yes

1

Accounting method used to prepare the Form 990:
Cash
Accrual
Other
If the organization changed its method of accounting from a prior year or checked “Other,” explain in
Schedule O.

2a

Were the organization’s financial statements compiled or reviewed by an independent accountant? . . .
If “Yes,” check a box below to indicate whether the financial statements for the year were compiled or
reviewed on a separate basis, consolidated basis, or both:

Separate basis
Consolidated basis
Both consolidated and separate basis
b Were the organization’s financial statements audited by an independent accountant?
. . . . . . .
If “Yes,” check a box below to indicate whether the financial statements for the year were audited on a
separate basis, consolidated basis, or both:

Separate basis
Consolidated basis
Both consolidated and separate basis
If “Yes” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight
of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in
Schedule O.
3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in
the Single Audit Act and OMB Circular A-133? . . . . . . . . . . . . . . . . . . . . .
b If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the
required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits

No

2a

2b

c

2c

3a
3b
Form 990 (2012)