990 Schedule G Supplemental Information Regarding Fundraising or Gaming

SCHEDULE G
(Form 990)
Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding Fundraising or Gaming Activities
Complete if the organization answered “Yes” on Form 990, Part IV, line 17, 18, or 19, or if the
organization entered more than $15,000 on Form 990-EZ, line 6a.
▶ Attach to Form 990 or Form 990-EZ.
▶ Go to www.irs.gov/Form990 for instructions and the latest information.

2021

Open to Public
Inspection

Employer identification number

Name of the organization

Part I

OMB No. 1545-0047

Fundraising Activities. Complete if the organization answered “Yes” on Form 990, Part IV, line 17.
Form 990-EZ filers are not required to complete this part.

1

Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a
Mail solicitations
e
Solicitation of non-government grants
b
f
Internet and email solicitations
Solicitation of government grants
Phone solicitations
Special fundraising events
c
g
d
In-person solicitations
2a Did the organization have a written or oral agreement with any individual (including officers, directors, trustees,
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
Yes
No
b If “Yes,” list the 10 highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is to be
compensated at least $5,000 by the organization.

(i) Name and address of individual
or entity (fundraiser)

(ii) Activity

(iii) Did fundraiser have
custody or control of
contributions?

Yes

(iv) Gross receipts
from activity

(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i)

(vi) Amount paid to
(or retained by)
organization

No

1
2
3
4
5
6
7
8
9
10

Total
. . . . . . . . . . . . . . . . . . . . . . ▶
3
List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from
registration or licensing.

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

Cat. No. 50083H

Schedule G (Form 990) 2021

Page 2

Schedule G (Form 990) 2021

Direct Expenses

Revenue

Part II

1

Gross receipts .

2
3

Less: Contributions . .
Gross income (line 1 minus
line 2) . . . . . . .

4

Cash prizes .

5

Noncash prizes

.

.

.

.

.

6

Rent/facility costs .

.

.

7

Food and beverages .

.

8

Entertainment .

.

.

9

Other direct expenses

.

.

(a) Event #1

(b) Event #2

(c) Other events

(event type)

(event type)

(total number)

(d) Total events
(add col. (a) through
col. (c))

.

.

Part III

.

.

.

10
11

Revenue

Fundraising Events. Complete if the organization answered “Yes” on Form 990, Part IV, line 18, or reported more
than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with
gross receipts greater than $5,000.

Direct expense summary. Add lines 4 through 9 in column (d)
Net income summary. Subtract line 10 from line 3, column (d)

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.

.
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▶
▶

Gaming. Complete if the organization answered “Yes” on Form 990, Part IV, line 19, or reported more than
$15,000 on Form 990-EZ, line 6a.
(b) Pull tabs/instant
bingo/progressive bingo

(a) Bingo

(d) Total gaming (add
col. (a) through col. (c))

(c) Other gaming

Gross revenue .

.

.

.

2

Cash prizes .

.

.

.

3

Noncash prizes

.

.

.

4

Rent/facility costs .

.

.

5

Other direct expenses

.

6

Volunteer labor .

.

7

Direct expense summary. Add lines 2 through 5 in column (d)

.

.

.

.

.

.

.

.

▶

8

Net gaming income summary. Subtract line 7 from line 1, column (d) .

.

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.

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.

.

.

▶

Enter the state(s) in which the organization conducts gaming activities:
a Is the organization licensed to conduct gaming activities in each of these states? .
b If “No,” explain:

.

.

.

.

Direct Expenses

1

.

.

.

Yes
No

%

Yes
No

Yes
No

%

.

.

%

9

.

.

Yes

No

10a Were any of the organization’s gaming licenses revoked, suspended, or terminated during the tax year?
b If “Yes,” explain:

.

Yes

No

.

.

Schedule G (Form 990) 2021

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Schedule G (Form 990) 2021

11
12

Does the organization conduct gaming activities with nonmembers? . . . . . . . . . . . . .
Is the organization a grantor, beneficiary or trustee of a trust, or a member of a partnership or other entity
formed to administer charitable gaming? . . . . . . . . . . . . . . . . . . . . . .
13
Indicate the percentage of gaming activity conducted in:
13a
a The organization’s facility . . . . . . . . . . . . . . . . . . . . . . . . .
13b
b An outside facility . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
Enter the name and address of the person who prepares the organization’s gaming/special events books and
records:

Yes

No

Yes

No
%
%

Name ▶
Address ▶
15a

Does the organization have a contract with a third party from whom the organization receives gaming
revenue? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b If “Yes,” enter the amount of gaming revenue received by the organization ▶
$
and the
amount of gaming revenue retained by the third party ▶ $
c If “Yes,” enter name and address of the third party:

Yes

No

Yes

No

Name ▶
Address ▶
16

Gaming manager information:
Name ▶
Gaming manager compensation ▶

$

Description of services provided ▶
Director/officer

Employee

Independent contractor

17
a

Mandatory distributions:
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? . . . . . . . . . . . . . . . . . . . . . . . . .
b Enter the amount of distributions required under state law to be distributed to other exempt organizations or
$
spent in the organization’s own exempt activities during the tax year ▶

Part IV

Supplemental Information. Provide the explanations required by Part I, line 2b, columns (iii) and (v); and
Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also provide any additional information.
See instructions.

Schedule G (Form 990) 2021