Professional Documents
Culture Documents
8453-EO
12/31, 20 11
For use with Forms 990, 990-EZ, 990-PF, 1120-POL, and 8868
EXEMPT ORGANIZATION
Part I
12-3456789
Check the box for the type of return being filed with Form 8453-EO and enter the applicable amount, if any, from the return. If you
check the box on line 1a, 2a, 3a, 4a, or 5a below and the amount on that line of the return being filed with this form was blank, then
leave line 1b, 2b, 3b, 4b, or 5b, whichever is applicable, blank (do not enter -0-). If you entered -0- on the return, then enter -0- on the
applicable line below. Do not complete more than one line in Part I.
1a
2a
3a
4a
5a
Part II
6
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IX
I
I
I
I
b Total revenue, if any (Form 990, Part VIII, column (A), line 12)
b Total revenue, if any (Form 990-EZ, line 9)
b Total tax (Form 1120-POL, line 22)
b Tax based on investment income (Form 990-PF, Part VI, line 5)
b Balance due (Form 8868, Part I, line 3c or Part II, line 8c)
10053000.
1b
2b
3b
4b
5b
Declaration of Officer
I authorize the U.S. Treasury and its designated Financial Agent to initiate an Automated Clearing House (ACH) electronic funds
withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for payment of the
organization's federal taxes owed on this return, and the financial institution to debit the entry to this account. To revoke a payment,
I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment (settlement)
date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive confidential
information necessary to answer inquiries and resolve issues related to the payment.
If a copy of this return is being filed with a state agency(ies) regulating charities as part of the IRS Fed/State program, I certify that I
executed the electronic disclosure consent contained within this return allowing disclosure by the IRS of this Form 990/990-EZ/990PF (as specifically identified in Part I above) to the selected state agency(ies).
Under penalties of perjury, I declare that I am an officer of the above named organization and that I have examined a copy of the
organization's 2011 electronic return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,
correct, and complete. I further declare that the amount in Part I above is the amount shown on the copy of the organization's electronic
return. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO) to send the organization's return
to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason for any
delay in processing the return or refund, and (c) the date of any refund.
Sign
Here
Part III
04/12/2012
Signature of officer
Date
MCFO
Title
I declare that I have reviewed the above organization's return and that the entries on Form 8453-EO are complete and correct to the best of
my knowledge. If I am only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data
on the return. The organization officer will have signed this form before I submit the return. I will give the officer a copy of all forms and
information to be filed with the IRS, and have followed all other requirements in Pub. 4163, Modernized e-File (MeF) Information for Authorized
IRS e-file Providers for Business Returns. If I am also the Paid Preparer, under penalties of perjury I declare that I have examined the above
organization's return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and
complete. This Paid Preparer declaration is based on all information of which I have any knowledge.
ERO's
Use
Only
ERO's
signature
Date
Check if
also paid
preparer
EISNERAMPER LLP
750 THIRD AVENUE
NEW YORK
Check if
selfemployed
EIN
NY 10017-2703
P00736879
13-1639826
Phone no.
Under penalties of perjury, I declare that I have examined the above return and accompanying schedules and statements, and to the best of my knowledge
and belief, they are true, correct, and complete. Declaration of preparer is based on all information of which the preparer has any knowledge.
Print/Type preparer's name
Paid
Preparer
Use Only
Firm's name
Firm's address
Preparer's signature
I
I
Firm's EIN
Phone no.
if
PTIN
9:10:34 AM
I
Form
JSA
1E1675 1.000
4/3/2012
Check
self-employed
For Privacy Act and Paperwork Reduction Act Notice, see back of form.
90958W L161
Date
V 11-4.1
8453-EO
(2011)
Form
, 20
D Employer identification number
EXEMPT ORGANIZATION
12-3456789
Address
change
Doing Business As
Name change
Number and street (or P.O. box if mail is not delivered to street address)
Initial return
1 MAIN STREET
Terminated
Amended
return
Application
pending
G Gross receipts $
ANYCITY, NY 10001
affiliates?
13,603,000.
Yes
X No
Yes
No
527
L Year of formation:
1983
NY
Net Assets or
Fund Balances
E Telephone number
Room/suite
(555 ) 555-5555
EMPLOYEE A
1 MAIN STREET ANYCITY, NY 10001
Tax-exempt status:
I
X 501(c)(3)
501(c) (
)
(insert no.)
J Website:
WWW.EXEMPTORG.ORG
K Form of organization: X Corporation
Trust
Association
Other
Summary
Part I
1
Inspection
C Name of organization
Check if applicable:
Open to Public
The organization may have to use a copy of this return to satisfy state reporting requirements.
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung
benefit trust or private foundation)
2
3
4
5
6
7a
b
if the organization discontinued its operations or disposed of more than 25% of its net assets.
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Number of independent voting members of the governing body (Part VI, line 1b)
Total number of individuals employed in calendar year 2011 (Part V, line 2a)
Total number of volunteers (estimate if necessary)
Total unrelated business revenue from Part VIII, column (C), line 12
Net unrelated business taxable income from Form 990-T, line 34
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495,000.
I mmmmmmmmmmmmmmmm
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8
9
10
11
12
13
14
15
16 a
b
17
18
19
20
21
22
15.
13.
124.
8.
0
0
3
4
5
6
7a
7b
Number of voting members of the governing body (Part VI, line 1a)
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)
Prior Year
Current Year
9,458,000.
0
288,000.
337,000.
10,083,000.
0
0
4,152,000.
60,000.
9,458,000.
0
288,000.
307,000.
10,053,000.
0
0
4,062,000.
60,000.
4,601,000.
8,813,000.
1,270,000.
4,601,000.
8,723,000.
1,330,000.
Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25)
Revenue less expenses. Subtract line 18 from line 12
Part II
End of Year
21,301,000.
5,857,000.
15,444,000.
22,289,000.
5,703,000.
16,586,000.
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
M
M
Signature of officer
Date
Paid
Preparer
Firm's name
Use Only
Firm's address
Preparer's signature
I
I
Date
9:10:34 AM
Firm's EIN
P00736879
13-1639826
Phone no.
Yes
Form
JSA
1E1010 1.000
PTIN
I
mmmmmmmmmmmmmmmmmmmmmmmmmX
EISNERAMPER LLP
750 THIRD AVENUE NEW YORK, NY 10017-2703
May the IRS discuss this return with the preparer shown above? (see instructions)
Check
if
self-employed
V 11-4.1
No
990 (2011)
EXEMPT ORGANIZATION
12-3456789
Page 2
Part III
1
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2 Did the organization undertake any significant program services during the year which were not listed on the
prior Form 990 or 990-EZ?
If "Yes," describe these new services on Schedule O.
3 Did the organization cease conducting, or make significant changes in how it conducts, any program
services?
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X No
Yes
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X No
Yes
If "Yes," describe these changes on Schedule O.
4 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 and section 4947(a)(1) trusts 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 $
3,413,000.
including grants of $
) (Revenue $
including grants of $
) (Revenue $
including grants of $
) (Revenue $
4b (Code:
) (Expenses $
3,000,000.
4c (Code:
) (Expenses $
1,094,000.
JSA
1E1020 1.000
) (Revenue $
)
Form
9:10:34 AM
V 11-4.1
990
(2011)
EXEMPT ORGANIZATION
12-3456789
Page 3
Part IV
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1
2
3
4
5
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes,"
complete Schedule A
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
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
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
Did the organization report an amount in Part X, line 21; 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
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 organizations 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 investmentsothersecurities 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
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part X
1
2
X
X
X
3
4
No
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7
8
9
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10
11
a
b
c
d
10
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e
f Did the organizations separate or consolidated financial statements for the tax year include a footnote that addresses
the organization answered "No" to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional
11b
11d
11e
9:10:34 AM
V 11-4.1
X
X
11f
12a
X
X
X
X
12b
13
14a
14b
15
16
17
18
19
20a
20b
Form
JSA
11c
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1E1021 1.000
11a
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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, XII, and XIII
b Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if
X
X
990 (2011)
EXEMPT ORGANIZATION
12-3456789
Page 4
Part IV
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
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
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
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?
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
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
Was a loan to or by a current or former officer, director, trustee, key employee, highly 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):
A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV
A family member of a current or former officer, director, trustee, or key employee? If "Yes," complete
Schedule L, Part IV
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
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, Parts II, III,
IV, and V, line 1
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
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
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
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 11 and
19? Note. All Form 990 filers are required to complete Schedule O.
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21
22
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24 a
b
c
d
25 a
b
23
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24a
24b
X
X
24c
24d
X
X
25a
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m
26
27
25b
26
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28
a
b
c
29
30
31
32
33
34
35 a
b
36
37
38
28a
28b
28c
29
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31
32
33
34
35a
9:10:34 AM
V 11-4.1
X
X
35b
36
37
38
Form
X
X
30
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JSA
27
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1E1030 1.000
No
X
X
990 (2011)
EXEMPT ORGANIZATION
12-3456789
Page 5
Part V
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0
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Yes
1a
1 a Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable
1b
b Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable
c Did the organization comply with backup withholding rules for reportable payments to vendors and
reportable gaming (gambling) winnings to prize winners?
2 a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax
2a
Statements, filed for the calendar year ending with or within the year covered by this return
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)
3 a 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
4 a 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)?
CANADA
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.
5 a 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?
6 a 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?
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?
7d
d If "Yes," indicate the number of Forms 8282 filed during the year
1c
2b
3a
3b
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e
f
g
h
8
9
a
b
10
a
b
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?
5a
5b
5c
X
X
6a
6b
7a
7b
X
X
7c
7e
7f
7g
7h
X
X
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13
4a
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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?
No
9a
9b
12a
13a
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14 a 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
JSA
1E1040 1.000
14a
14b
Form
9:10:34 AM
V 11-4.1
X
990 (2011)
EXEMPT ORGANIZATION
Part VI
Page 6
12-3456789
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.
Check if Schedule O contains a response to any question in this Part VI
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1a
Yes
No
15
material differences in voting rights among members of the governing body, or if the governing body
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mmmmmmm
mmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
13
1b
b Enter the number of voting members included in line 1a, above, who are independent
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
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
5
Did the organization become aware during the year of a significant diversion of the organization's assets?
6
Did the organization have members or stockholders?
7a 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
X
X
X
X
7a
7b
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmm
X
X
8a
8b
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
mmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmm
mm
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmm
Yes
10b
11a
12a
12b
12c
13
14
X
X
X
mmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
15a
15b
No
10a
X
X
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
16a
mmmmmmmmmmmmmmmmmmmmmmmmmm
INY,
Section C. Disclosure
16b
17
18
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.
X Own website
X Upon request
Another's website
19
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: EMPLOYEE B 1 MAIN STREET ANYCITY, NY 10001
212 456-7890
Form 990 (2011)
20
JSA
1E1042 1.000
9:10:34 AM
V 11-4.1
Part VII
Page 7
EXEMPT ORGANIZATION
12-3456789
Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and
Independent Contractors
Check if Schedule O contains a response to any question in this Part VII
mmmmmmmmmmmmmmmmmmmm
Section A.
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.
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
compensated employees; and former such persons.
trustees
or directors;
institutional
trustees;
officers;
key employees;
highest
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title
(B)
Average
hours per
week
Highest compensated
employee
Key employee
Officer
Institutional trustee
Individual trustee
or director
(describe
hours for
related
organizations
in Schedule
O)
(C)
Position
(D)
Reportable
compensation
from
the
organization
(W-2/1099-MISC)
(E)
Reportable
compensation from
related
organizations
(W-2/1099-MISC)
(F)
Estimated
amount of
other
compensation
from the
organization
and related
organizations
(1) TRUSTEE A
CHAIRMAN
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
(2) TRUSTEE B
VICE CHAIR
(3) TRUSTEE C
TREASURER
(4) TRUSTEE D
TRUSTEE
(5) TRUSTEE E
TRUSTEE
(6) TRUSTEE F
TRUSTEE
(7) TRUSTEE G
TRUSTEE
(8) TRUSTEE H
TRUSTEE
(9) TRUSTEE I
TRUSTEE
(10) TRUSTEE J
TRUSTEE
(11) TRUSTEE K
TRUSTEE
(12) TRUSTEE L
TRUSTEE
(13) TRUSTEE M
TRUSTEE
(14) TRUSTEE N
TRUSTEE
0
Form
JSA
1E1041 1.000
9:10:34 AM
V 11-4.1
990
(2011)
EXEMPT ORGANIZATION
12-3456789
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees(continued)
(A)
Name and title
(B)
(C)
Average
Position
(do not check more than one
box, unless person is both an
officer and a director/trustee)
hours per
week
(describe
Former
2.00
Highest compensated
employee
( 15) TRUSTEE O
TRUSTEE
( 16) EMPLOYEE A
CEO
( 17) EMPLOYEE B
CFO
( 18) EMPLOYEE C
DIRECTOR OF DEVELOPMENT
( 19) EMPLOYEE D
PROGRAM DIRECTOR
( 20) EMPLOYEE E
PROGRAM DIRECTOR
( 21) EMPLOYEE F
PROGRAM DIRECTOR
Key employee
O)
Officer
in Schedule
Institutional trustee
related
organizations
Individual trustee
or director
hours for
(D)
Reportable
compensation
from
the
organization
(W-2/1099-MISC)
(E)
Reportable
compensation from
related
organizations
(W-2/1099-MISC)
(F)
Estimated
amount of
other
compensation
from the
organization
and related
organizations
35.00
240,000.
7,000.
35.00
200,000.
5,000.
180,000.
5,000.
35.00
35.00
160,000.
3,000.
35.00
160,000.
3,000.
35.00
160,000.
3,000.
0
0
0
0
26,000.
26,000.
mmmmmmmmmmmmmmmmmmmmmmmmmm
m
m
m
m
m
m
m
m
m
m
m
m
I
m
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmmmmmmmmmmmmmmmmmmmmmmmmI
I
I
1b
c
d
2
0
Sub-total
1,100,000.
Total from continuation sheets to Part VII, Section A
1,100,000.
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
6
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
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
Yes
mmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmm
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
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.
5
(A)
Name and business address
(B)
Description of services
LEGAL FEES
MGMT. CONSUL. FEES
No
(C)
Compensation
100,000.
160,000.
Total number of independent contractors (including but not limited to those listed above) who received
more than $100,000 in compensation from the organization
1
JSA
1E1055 2.000
9:10:34 AM
V 11-4.1
Form
990
(2011)
Part VIII
EXEMPT ORGANIZATION
Statement of Revenue
(A)
Total revenue
mmmmmmmm
mmmmmmmmm
mmmmmmmmm
mmmmmmmm
mm
m
mmmmmmmmmmmmmmmmmmm
I
Federated campaigns
1a
Membership dues
1b
Fundraising events
Related organizations
1d
1e
2,519,000.
1f
5,644,000.
850,000.
1a
g
h
1c
(B)
Related or
exempt
function
revenue
(C)
Unrelated
business
revenue
(D)
Revenue
excluded from tax
under sections
512, 513, or 514
1,295,000.
9,458,000.
Business Code
2a
b
c
d
e
f
g
3
mmmmmmm
mm
mm
mm
mm
mmmmmmmmm
I
mmmmmmmmmmmmmmmmmmm
I
m
m
m
I
mmmmmmmmmmmmmmmmmmmmmmmmm
I
mmmmmmmm
mmm
mm
mmmmmmmmmmmmmmmmm
I
188,000.
Royalties
6a
c
d
(i) Real
(ii) Personal
(i) Securities
(ii) Other
8a
3,300,000.
mmmm
mmm
mm
mm
mm
mm
mmmmmmmmmmmmmmmmm
I
3,200,000.
188,000.
Gross rents
7a
Other Revenue
Page 9
12-3456789
100,000.
Gain or (loss)
Net gain or (loss)
100,000.
1,295,000.
mmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
I
mmmmmmmmmmm
mmmmmmmmmmmmmmmmmmm
I
mmmmmmmmm
mmmmmmmmmmmmmmmmmm
I
280,000.
280,000.
11a
less
276,000.
70,000.
Less: cost of goods sold
b
Net income or (loss) from sales of inventory
Miscellaneous Revenue
Business Code
206,000.
206,000.
MISCELLANEOUS REVENUE
101,000.
101,000.
b
c
mmmmm
m
m
m
m
m
mm
mm
mm
m
m
m
m
m
I
mmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
m
I
12
101,000.
10,053,000.
495,000.
Form
JSA
1E1051 1.000
9:10:34 AM
V 11-4.1
990
(2011)
EXEMPT ORGANIZATION
Statement of Functional Expenses
Part IX
Page 10
12-3456789
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not
required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX
mmmmmmmmmmmmmmmmmmmmmmmmmm
(A)
Total expenses
m
mmmmmm
(B)
Program service
expenses
(C)
Management and
general expenses
(D)
Fundraising
expenses
mmmm
mmmmmmmmm
mmmmmmmmmm
mmmmmm
mmmmmmmmmmmm
mmmmmm
mmmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
mmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmmmmmmmmmmmmmmm
mmmmmmmmm
mmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmm
mmmmmmmmmmmmmmmm
mmmmmmmmmmmmm
mm
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmm
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmmmmmmmmmmmmmmmmm
0
0
620,000.
269,000.
220,000.
131,000.
0
2,232,000.
2,084,000.
115,000.
33,000.
315,000.
710,000.
185,000.
234,000.
665,000.
148,000.
41,000.
36,250.
27,750.
40,000.
8,750.
9,250.
160,000.
100,000.
20,000.
6,000.
60,000.
30,000.
69,000.
19,000.
558,000.
81,000.
0
466,000.
0
160,000.
90,000.
5,000.
5,000.
6,000.
5,000.
15,000.
and
10
11
a Management
b Legal
c Accounting
d Lobbying
13
Office expenses
14
Information technology
15
Royalties
16
Occupancy
17
Travel
18
19
20
Interest
21
Payments to affiliates
22
23
Insurance
24
Other
expenses
not
375,000.
57,000.
9,000.
121,000.
15,000.
435,000.
20,000.
11,000.
39,000.
0
55,000.
70,000.
0
390,000.
72,000.
40,000.
7,000.
70,000.
8,000.
357,000.
54,000.
12,000.
13,000.
21,000.
5,000.
2,496,000.
9,000.
2,496,000.
4,000.
2,000.
3,000.
8,723,000.
7,507,000.
721,000.
495,000.
69,000.
30,000.
mmmm
mmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmm
mmmm
mmmmmmmmmmmmmmmmmmm
expenses. Itemize
60,000.
30,000.
30,000.
10,000.
62,000.
9,000.
covered
a PROGRAM
b OTHER
SUPPLIES
EXPENSES
c
d
e All other expenses
25
26
I
m
mmmmmm
JSA
1E1052 1.000
39,000.
Form
9:10:34 AM
V 11-4.1
990 (2011)
EXEMPT ORGANIZATION
12-3456789
Page 11
Part X
Assets
Liabilities
mmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmm
Cash - non-interest-bearing
Savings and temporary cash investments
Pledges and grants receivable, net
Accounts receivable, net
Receivables from current and former officers, directors, trustees, key
employees, and highest compensated employees. Complete Part II of
Schedule L
6 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)
7 Notes and loans receivable, net
8 Inventories for sale or use
9 Prepaid expenses and deferred charges
10 a Land, buildings, and equipment: cost or
7,596,000.
other basis. Complete Part VI of Schedule D 10a
1,867,000.
10b
b Less: accumulated depreciation
11
Investments - publicly traded securities
12
Investments - other securities. See Part IV, line 11
13
Investments - program-related. See Part IV, line 11
14
Intangible assets
15
Other assets. See Part IV, line 11
16
Total assets. Add lines 1 through 15 (must equal line 34)
17
Accounts payable and accrued expenses
18
Grants payable
19
Deferred revenue
20
Tax-exempt bond liabilities
21
Escrow or custodial account liability. Complete Part IV of Schedule D
22
Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified persons.
Complete Part II of Schedule L
23
Secured mortgages and notes payable to unrelated third parties
24
Unsecured notes and loans payable to unrelated third parties
25
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
Total liabilities. Add lines 17 through 25
26
X and complete
Organizations that follow SFAS 117, check here
lines 27 through 29, and lines 33 and 34.
1
2
3
4
5
Balance Sheet
503,000. 1
3,968,000. 2
4,150,000. 3
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmmmmmmmmm
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmmmmm
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmmmmmmmmmmmmmmmm
6
7
8
9
mmmmmmmmmmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
I
mmmmmmmmmmmmmmmmmmmmmmmmmmmmm
m
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
I
mmmmmmmmmmmmmmmm
mmmmmmmm
mmmm
mmmmmmm
m
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmmmmmmmmmmm
mm
mm
mm
m
JSA
1E1053 1.000
9:10:34 AM
V 11-4.1
650,000.
3,553,000.
4,283,000.
mmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmm
mmmmmmmmm
30
31
32
33
34
(B)
End of year
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmm
mmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
mmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmm
27
28
29
(A)
Beginning of year
31,000.
55,000.
4,761,000. 10c
6,000,000. 11
1,830,000. 12
3,000.
21,301,000.
569,000.
290,000.
4,000,000.
13
14
15
16
17
18
19
20
21
34,000.
37,000.
5,729,000.
5,500,000.
2,500,000.
3,000.
22,289,000.
671,000.
301,000.
3,700,000.
22
23
24
998,000. 25
5,857,000. 26
1,031,000.
5,703,000.
6,950,000. 27
2,494,000. 28
6,000,000. 29
7,321,000.
2,491,000.
6,774,000.
and
30
31
32
15,444,000. 33
21,301,000. 34
16,586,000.
22,289,000.
Form 990 (2011)
EXEMPT ORGANIZATION
12-3456789
Page 12
Part XI
mmmmmmmmmmmmmmmmmmmmmmmX
10,053,000.
mmmmmmmmmmmmmmmmmmmmmmmmmm
8,723,000.
mmmmmmmmmmmmmmmmmmmmmmmmmm
1,330,000.
mmmmmmmmmmmmmmmmmmmmmmmmmmmm
15,444,000.
mmmmmmmm
-188,000.
mmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
16,586,000.
Financial Statements and Reporting
mmmmmmmmmmmmmmmmmmmmmm
Reconciliation of Net Assets
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))
Other changes in net assets or fund balances (explain in Schedule O)
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33,
column (B))
Part XII
1
2
3
4
5
6
Yes
1
2a
b
c
3a
b
X Accrual
Accounting method used to prepare the Form 990:
Cash
Other
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
Were the organization's financial statements compiled or reviewed by an independent accountant?
Were the organization's financial statements audited by an independent accountant?
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.
If "Yes" to line 2a or 2b, check a box below to indicate whether the financial statements for the year were
issued on a separate basis, consolidated basis, or both:
Both consolidated and separate basis
X Separate basis
Consolidated basis
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?
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
mmmmmmmm
mmmmmmmmmmmmmmmm
mmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
2a
2b
2c
JSA
9:10:34 AM
V 11-4.1
3a
3b
Form
1E1054 1.000
No
990
(2011)
SCHEDULE A
Open to Public
Inspection
EXEMPT ORGANIZATION
12-3456789
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
Part I
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.)
3
A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).
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:
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
A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).
7 X 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.)
8
A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)
9
An organization that normally receives: (1) more than 33 1/3 % 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 33 1/3% 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
An organization organized and operated exclusively to test for public safety. See section 509(a)(4).
11
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 - Other
e
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).
f
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
g
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)
11g(i)
and (iii) below, the governing body of the supported organization?
11g(ii)
(ii) A family member of a person described in (i) above?
11g(iii)
(iii) A 35% controlled entity of a person described in (i) or (ii) above?
h
Provide the following information about the supported organization(s).
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmm
(ii) EIN
(iv) Is the
organization in
col. (i) listed in
your governing
document?
Yes
No
Yes
No
(vi) Is the
organization in
col. (i) organized
in the U.S.?
Yes
(vii) Amount of
support
No
(A)
(B)
(C)
(D)
(E)
Total
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.
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EXEMPT ORGANIZATION
12-3456789
Page 2
Part II
Gifts,
grants,
contributions,
and
membership fees received. (Do not
include any "unusual grants.")
mmmmmm
Tax
revenues
levied
for
the
organization's benefit and either paid
to or expended on its behalf
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
8,713,000.
9,378,000.
9,738,000.
9,287,000.
9,458,000.
46,574,000.
8,713,000.
9,378,000.
9,738,000.
9,287,000.
9,458,000.
46,574,000.
mmmmmmm
mmmmmmm
mmmmmmm
mmmmmmm
876,920.
45,697,080.
mmmmmmmmI
mm
7
8
mmmmmmmmmmmmmmmmm
10
11
12
13
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
8,713,000.
9,378,000.
9,738,000.
9,287,000.
9,458,000.
46,574,000.
1,082,000.
228,000.
218,000.
71,000.
288,000.
1,887,000.
mmmmmmmmmm
mmmmmmmmmmm
mm
mmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
I
Section C. Computation of Public Support Percentage
92.64
mmmmmmmm
94.95
mmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmm
IX
mmmmmmmmmmmmmmmmm
I
31,000.
286,000.
242,000.
307,000.
866,000.
49,327,000.
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
14
14 Public support percentage for 2011 (line 6, column (f) divided by line 11, column (f))
15
15 Public support percentage from 2010 Schedule A, Part II, line 14
16a 33 1/3 % support test - 2011. If the organization did not check the box on line 13, and line 14 is 33 1/3 % or more, check
this box and stop here. The organization qualifies as a publicly supported organization
b 33 1/3 % support test - 2010. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3 % or more,
check this box and stop here. The organization qualifies as a publicly supported organization
17a 10%-facts-and-circumstances test - 2011. 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 - 2010. 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 organzation 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
%
%
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
I
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
I
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
I
Schedule A (Form 990 or 990-EZ) 2011
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EXEMPT ORGANIZATION
12-3456789
Page 3
Part III
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
or
services
performed,
or
facilities
mmmmmm
m
Tax
revenues
levied
for
the
value
of
services
mmmmmmm
or
facilities
mmmmmmm
mmmmmmm
mmmm
received
from
other
than
disqualified
persons that exceed the greater of $5,000
or 1% of the amount on line 13 for the year
mmmmmmmmmmm
mmmmmmmmmmmmmmmmm
Section B. Total Support
I
mmmmmmmmmm
m
8
line 6.)
mmmmmmmmmmmmmmmmm
section
511
taxes) from
businesses
mmmmmm
mmmmmmmmm
11
mmmmmmmmmmmmmmm
12
mmmmmmmmmmm
mmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
I
Section C. Computation of Public Support Percentage
mmmmmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
Section D. Computation of Investment Income Percentage
mmmmmmmmmm
mmmmmmmmmmmmmmmmmmmm
I
I
I
13
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)
and 12.)
15
Public support percentage for 2011 (line 8, column (f) divided by line 13, column (f))
15
16
16
17
Investment income percentage for 2011 (line 10c, column (f) divided by line 13, column (f))
17
18
18
%
%
%
%
If the organization did not check the box on line 14, and line 15 is more than 33 1/3 %, and line
17 is not more than 33 1/3 %, check this box and stop here . The organization qualifies as a publicly supported organization
b 33 1/3 % support tests - 2010. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3 %, and
20
line 18 is not more than 33 1/3 %, 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
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Page 4
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).
CONTRIBUTOR NAME
LESS 2% OF
LINE 11(F)
EXCESS
CONTRIBUTION
AMOUNT
DONOR A
1,250,000.
986,540.
263,460.
DONOR D
1,600,000.
986,540.
613,460.
TOTAL
2,850,000.
876,920.
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Schedule B
Schedule of Contributors
EXEMPT ORGANIZATION
12-3456789
Organization type (check one):
Filers of:
Section:
501(c)( 3
For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.
Special Rules
For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33 1/3 % support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of
the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1.
Complete Parts I and II.
For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use
exclusively for religious, charitable, scientific, literary,
or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and III.
For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during the
year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or
more during the year
$
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer "No" on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ or on
Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions for Form 990, 990-EZ, or 990-PF.
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Page 2
EXEMPT ORGANIZATION
12-3456789
Part I Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
DONOR A
C/O EXEMPT ORG 1 MAIN STREET
ANYCITY, NY
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
DONOR B
ANYCITY, NY
(a)
No.
(c)
Total contributions
DONOR C
(a)
No.
(c)
Total contributions
AGENCY 1
(a)
No.
(c)
Total contributions
AGENCY 2
(a)
No.
519,000.
(d)
Type of contribution
Person
Payroll
Noncash
(d)
Type of contribution
Person
Payroll
Noncash
(d)
Type of contribution
Person
Payroll
Noncash
10001
(b)
Name, address, and ZIP + 4
(c)
Total contributions
DONOR D
C/O EXEMPT ORG 1 MAIN STREET
ANYCITY, NY
Person
Payroll
Noncash
2,000,000.
10001
(b)
Name, address, and ZIP + 4
ANYCITY, NY
(d)
Type of contribution
325,000.
10001
(b)
Name, address, and ZIP + 4
ANYCITY, NY
450,000.
10001
(b)
Name, address, and ZIP + 4
ANYCITY, NY
Person
Payroll
Noncash
10001
575,000.
(d)
Type of contribution
704,000.
(d)
Type of contribution
Person
Payroll
Noncash
X
X
10001
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Page 3
Name of organization
EXEMPT ORGANIZATION
12-3456789
Part II
(a) No.
from
Part I
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(c)
FMV (or estimate)
(see instructions)
(b)
Description of noncash property given
(d)
Date received
DONATED SECURITIES
6
$
(a) No.
from
Part I
(b)
Description of noncash property given
704,000.
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a) No.
from
Part I
(b)
Description of noncash property given
$
(a) No.
from
Part I
(b)
Description of noncash property given
$
(a) No.
from
Part I
(b)
Description of noncash property given
$
(a) No.
from
Part I
(b)
Description of noncash property given
$
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
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Page 4
Name of organization
EXEMPT ORGANIZATION
12-3456789
Part III Exclusivelyreligious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.)
$
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I
(a) No.
from
Part I
(a) No.
from
Part I
(a) No.
from
Part I
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SCHEDULE C
For Organizations Exempt From Income Tax Under section 501(c) and section 527
Open to Public
Inspection
If the organization answered "Yes" to Form 990, Part IV, line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
%
%
%
%
%
%
Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" to Form 990, Part IV, line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" to Form 990, Part IV, line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Name of organization
EXEMPT ORGANIZATION
12-3456789
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.
1
2
3
Provide a description of the organization's direct and indirect political campaign activities in Part IV.
Political expenditures
Volunteer hours
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
m
Part
I-B
4
1
2
3
4a
b
1
2
3
4
5
mmmmmmI
mmI
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
Enter the amount of any excise tax incurred by the organization under section 4955
Enter the amount of any excise tax incurred by organization managers under section 4955
If the organization incurred a section 4955 tax, did it file Form 4720 for this year?
Was a correction made?
If "Yes," describe in Part IV.
Part I-C
$
$
Yes
No
Yes
No
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
Enter the amount directly expended by the filing organization for section 527 exempt function
$
activities
Enter the amount of the filing organization's funds contributed to other organizations for section
$
527 exempt function activities
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL,
$
line 17b
Did the filing organization file Form 1120-POL for this year?
Yes
No
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization's funds. Also enter
the amount of political contributions received that were promptly and directly delivered to a separate political organization, such
as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmmmmmmmmmmmmmmm
(a) Name
(b) Address
(c) EIN
(1)
(2)
(3)
(4)
(5)
(6)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
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Page 2
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under
section 501(h)).
if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's
name, address, EIN, expenses, and share of excess lobbying expenditures).
if the filing organization checked box A and "limited control" provisions apply.
Part II-A
I
Check I
A Check
B
1a
b
c
d
e
f
(a) Filing
organization's totals
mmmmmm
mmmmmmm
mmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmm
(b) Affiliated
group totals
6,000.
6,000.
8,717,000.
8,723,000.
586,150.
If the amount on line 1e, column (a) or (b) is: The lobbying nontaxable amount is:
g
h
i
j
Over $17,000,000
$1,000,000.
mmmmmmmmmmmmmmmmmmm 146,538.0
mmmmmmmmmmmmmmmmmmm
0
mmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
0
0
Yes
X No
(a) 2008
145,000.
(b) 2009
595,650.
(c) 2010
595,650.
(d) 2011
589,000.
(e) Total
1,925,300.
2,887,950.
147,000.
145,000.
145,000.
6,000.
296,000.
148,913.
148,913.
141,000.
585,826.
878,739.
145,000.
145,000.
145,000.
6,000.
441,000.
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Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768
(election under section 501(h)).
For each "Yes" response to lines 1a through 1i below, provide in Part IV a detailed description
of the lobbying activity.
1
a
b
c
d
e
f
g
h
i
j
2a
b
c
d
Yes
(b)
No
Amount
During the year, did the filing organization attempt to influence foreign, national, state or local
legislation, including any attempt to influence public opinion on a legislative matter or
referendum, through the use of:
Volunteers?
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)?
Media advertisements?
Mailings to members, legislators, or the public?
Publications, or published or broadcast statements?
Grants to other organizations for lobbying purposes?
Direct contact with legislators, their staffs, government officials, or a legislative body?
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means?
Other activities?
Total. Add lines 1c through 1i
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)?
If "Yes," enter the amount of any tax incurred under section 4912
If "Yes," enter the amount of any tax incurred by organization managers under section 4912
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year?
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
m
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmm
m
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
mmmmmm
mmmm
mmmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
mmm
mmmmmmmmmmmmmmmm
mmmm
mm
m
Part III-A
1
2
3
(a)
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section
501(c)(6).
mmmmmmmmmmmmmmmmmmm
mmmmmmmm
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
Part III-B
Yes
No
1
2
3
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section
501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is
answered "Yes."
mmmmmmmmmmmmmmmmmmmmmmmmmmmm
1
2
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmm
2a
2b
2c
3
mmmmmmmmmmmmmmmmmmmm
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
Part IV
4
5
Supplemental Information
Complete this part to provide the descriptions required for Part I-A, line 1; Part I-B, line 4; Part I-C, line 5; Part II-A; and Part II-B, line
1. Also, complete this part for any additional information.
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Page 4
Part IV
12-3456789
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SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Name of the organization
Open to Public
Inspection
Employer identification number
EXEMPT ORGANIZATION
12-3456789
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts.Complete if the
organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds
mmmmmmmmmmm
mmmm
mmmmmmm
mmmmmmmmmm
1
2
3
4
5
6
mmmmmmmmmmm
Yes
No
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
Yes
No
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
Part II
Purpose(s) of conservation easements held by the organization (check all that apply).
mmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmm
mmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmm
2a
Total number of conservation easements
2b
Total acreage restricted by conservation easements
2c
Number of conservation easements on a certified historic structure included in (a)
Number of conservation easements included in (c) acquired after 8/17/06, and not on a
2d
historic structure listed in the National Register
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year
Number of states where property subject to conservation easement is located
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of
violations, and enforcement of the conservation easements it holds?
Yes
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)
(i) and section 170(h)(4)(B)(ii)?
Yes
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organizations financial statements that describes the
organizations accounting for conservation easements.
a
b
c
d
3
4
5
I
mmmmmmmmmmmmmmmmmmmmmmm
No
I
I
$
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
Part III
1a
b
2
a
b
No
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet
works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of
public service, provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet
works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of
public service, provide the following amounts relating to these items:
(i) Revenues included in Form 990, Part VIII, line 1
$
(ii) Assets included in Form 990, Part X
$
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
Revenues included in Form 990, Part VIII, line 1
$
Assets included in Form 990, Part X
$
mmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
I
mmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mI
I
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
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EXEMPT ORGANIZATION
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Page 2
Part III
3
Using the organization's acquisition, accession, and other records, check any of the following that are a significant use of its
collection items (check all that apply):
Public exhibition
Loan or exchange programs
a
d
Scholarly research
Other
b
e
Preservation for future generations
c
4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part
XIV.
5 During the year, did the organization solicit or receive donations of art, historical treasures, or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization's collection?
Yes
No
mmmmmm
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990, Part IV,
line 9, or reported an amount on Form 990, Part X, line 21.
1a Is the organization an agent, trustee, custo dian or other intermediary for contributions or other assets not
included on Form 990, Part X?
b If "Yes," explain the arrangement in Part XI V and complete the following table:
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
Yes
No
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmm
Yes
No
Amount
c
d
e
f
2a
b
Beginning balance
Additions during the year
Distributions during the year
Ending balance
Did the organization include an amount on Form 990, Part X, line 21?
If "Yes," explain the arrangement in Part XI V.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
mmmm 6,301,000.
mmmmmmmmmmm 798,000.
mmmmmmmmmmmmm 45,000.
mmmmmm
m
mmmmmmmmmmm 45,000.
mmmmm
mmmmmmmm 7,099,000.
I 5.0000
I95.0000
I
(a) Current year
1c
1d
1e
1f
5,801,000.
500,000.
5,601,000.
200,000.
5,250,000.
351,000.
28,000.
30,000.
35,000.
28,000.
30,000.
35,000.
6,301,000.
5,801,000.
5,601,000.
Provide the estimated percentage of the c urrent year end balance (line 1g, column (a)) held as:
Board designated or quasi-endowment
%
Permanent endowment
%
Temporarily restricted endowment
%
The percentages in lines 2a, 2b, and 2c sh ould equal 100%.
3a Are there endowment funds not in the pos session of the organization that are held and administered for the
organization by:
(i) unrelated organizations
(ii) related organizations
b If "Yes" to 3a(ii), are the related organizati ons listed as required on Schedule R?
4 Describe in Part XIV the intended uses of t he organization's endowment funds.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
Part VI
Yes
3a(i)
3a(ii)
3b
No
X
X
(c) Accumulated
(investment)
(other)
depreciation
mmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
mmmmmmmmmm
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmm
1a Land
b Buildings
4,500,000. 1,106,000.
c Leasehold improvements
1,172,000.
288,000.
d Equipment
1,924,000.
473,000.
e Other
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)
mmmmmm
I
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9:10:34 AM
V 11-4.1
3,394,000.
884,000.
1,451,000.
5,729,000.
Schedule D (Form 990) 2011
EXEMPT ORGANIZATION
12-3456789
Page 3
Part VII
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmm
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)
Part VIII
FMV
FMV
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 13.)
Part IX
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 15.)
Part X
1.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
650,000.
150,000.
231,000.
Total. (Column (b) must equal Form 990, Part X, col. (B) line 25.)
1,031,000.
2. FIN 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the
organization's liability for uncertain tax positions under FIN 48 (ASC 740).
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EXEMPT ORGANIZATION
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Page 4
Part XI
Reconciliation of Change in Net Assets from Form 990 to Audited Financial Statements
mmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmm
mm
mm
mm
mm
mm
mm
m
Total revenue (Form 990, Part VIII, column (A), line 12)
Total expenses (Form 990, Part IX, column (A), line 25)
Excess or (deficit) for the year. Subtract line 2 from line 1
Net unrealized gains (losses) on investments
Donated services and use of facilities
Investment expenses
Prior period adjustments
Other (Describe in Part XIV.)
Total adjustments (net). Add lines 4 through 8
Excess or (deficit) for the year per audited financial statements. Combine lines 3 and 9
1
2
3
4
5
6
7
8
9
10
Part XII
1
2
a
b
c
d
e
3
4
a
b
c
5
1
2
a
b
c
d
e
3
4
a
b
c
5
-60,000.
-188,000.
1,142,000.
mmmmmmmmmmmmmmmmm
-158,000.
mmmmmmmmmmmmmmmmmmmmmm
542,000.
mmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmm
30,000.
mmmmmmmmmmmmmmmmmmmmmmmmmmm
mmm
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
m
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mm
mm
mm
mm
m
10,467,000.
2e
3
414,000.
10,053,000.
2a
2b
2c
2d
mmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
mmmmmmmmmmmmmmmmmmmmmmmm
542,000.
mmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
90,000.
mmmmmmmmmmmmmmmmmmmmmmmmmmm
mmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
30,000.
mmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
Part XIV
30,000.
Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
Total revenue, gains, and other support per audited financial statements
Amounts included on line 1 but not on Form 990, Part VIII, line 12:
Net unrealized gains on investments
Donated services and use of facilities
Recoveries of prior year grants
Other (Describe in Part XIV.)
Add lines 2a through 2d
Subtract line 2e from line 1
Amounts included on Form 990, Part VIII, line 12, but not on line 1 :
Investment expenses not included on Form 990, Part VIII, line 7b
Other (Describe in Part XIV.)
Add lines 4a and 4b
Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.)
Part XIII
10,053,000.
8,723,000.
1,330,000.
-158,000.
1
2
3
4
5
6
7
8
9
10
4a
4b
4c
5
10,053,000.
9,325,000.
2e
3
632,000.
8,693,000.
4c
5
30,000.
8,723,000.
2a
2b
2c
2d
4a
4b
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part IV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide
any additional information.
SEE PAGE 5
9:10:34 AM
V 11-4.1
EXEMPT ORGANIZATION
Supplemental Information (continued)
12-3456789
Part XIV
Page 5
FOR THE
TAX-EXEMPT STATUS, ASC 740-10-05 DID NOT HAVE, AND IS NOT ANTICIPATED TO
HAVE, A MATERIAL IMPACT ON THE ORGANIZATION'S FINANCIAL STATEMENTS.
$ 30,000
$(60,000)
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EXEMPT ORGANIZATION
Supplemental Information (continued)
12-3456789
Part XIV
Page 5
$ 30,000
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SCHEDULE G
Complete if the organization answered "Yes" to Form 990, Part IV, lines 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.
See separate instructions.
Open to Public
Inspection
EXEMPT ORGANIZATION
12-3456789
Fundraising Activities.Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
Part I
Form 990-EZ filers are not required to complete this part.
1
a
b
c
d
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
X Mail solicitations
e X Solicitation of non-government grants
Internet and email solicitations
f X Solicitation of government grants
Phone solicitations
g X Special fundraising events
X In-person solicitations
2 a 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?
X Yes
No
b If "Yes," list the ten 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
Yes
1
FUNDRAISING
R US
FUNDRAISING
SPECIAL
EVENT
No
1,355,000.
60,000.
1,295,000.
2
3
4
5
6
7
8
9
10
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
1,355,000.
60,000. 1,295,000.
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.
NY,
Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
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Page 2
Part II
Fundraising Events.Complete if the organization answered "Yes" to 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.
(a) Event #1
(b) Event #2
(event type)
(total number)
ANNUAL DINNER
Revenue
(event type)
mmmmmmmmmmmm
mmmmmmmmmmmmm
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmmmmmmmmm
mmmmmmmmmm
mmmmmmmmm
mmmmmmmmmmmm
mmmmmmmm
1 Gross receipts
2 Less: Charitable
contributions
3 Gross income (line 1 minus
line 2)
1,575,000.
1,575,000.
1,295,000.
1,295,000.
280,000.
280,000.
280,000.
280,000.
4 Cash prizes
Direct Expenses
5 Noncash prizes
6 Rent/facility costs
280,000.
m
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mI
I
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more
(
Part III
Revenue
(a) Bingo
mmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmmmmmmmmm
mmmmmmmmmm
mmmmmmmm
mmmmmmmmmmm
1 Gross revenue
Direct Expenses
2 Cash prizes
3 Noncash prizes
4 Rent/facility costs
Yes
Yes
No
No
Yes
No
mmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmmmm
Yes
No
mmmm
Yes
No
10 a Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year?
b If "Yes," explain:
9:10:34 AM
V 11-4.1
EXEMPT ORGANIZATION
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Page 3
mmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
11
12
Name
Yes
No
Yes
No
%
%
I
I
Address
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:
15 a
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
I
I
Name
Yes
No
Yes
No
I
I
Address
16
Name
I
I
$
Employee
Independent contractor
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
$
a
Part IV
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
I
Supplemental Information. Complete this part to provide the explanation 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 complete this
part to provide any additional information (see instructions).
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9:10:34 AM
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Compensation Information
SCHEDULE J
(Form 990)
Department of the Treasury
Internal Revenue Service
I
I
Open to Public
Inspection
EXEMPT ORGANIZATION
Part I
Questions Regarding Compensation
12-3456789
Yes
No
1a Check the appropriate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b If any of the boxes on line 1a are checked, did the organization follow a written policy regarding payment
or reimbursement or provision of all of the expenses described above? If "No," complete Part III to
explain
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a?
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmm
X Compensation committee
During the year, did any person listed in Form 990, Part VII, Section A, line 1a, with respect to the filing
organization or a related organization:
a Receive a severance payment or change-of-control payment?
b Participate in, or receive payment from, a supplemental nonqualified retirement plan?
c Participate in, or receive payment from, an equity-based compensation arrangement?
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
mmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmmmmmmmmmmmmm
5
a
b
6
a
b
7
8
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods used by a
related organization to establish compensation of the CEO/Executive Director. Explain in Part III.
1b
4a
4b
4c
X
X
X
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
5a
5b
X
X
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
6a
6b
X
X
mmmmmmmmmmmmmmmmmmmmmmmm
Only section 501(c)(3) and 501(c)(4) organizations must complete lines 5-9.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
The organization?
Any related organization?
If "Yes" to line 5a or 5b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
The organization?
Any related organization?
If "Yes" to line 6a or 6b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
Were any amounts reported in Form 990, Part VII, paid or accrued pursuant to a contract that was subject
to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in
Regulations section 53.4958-6(c)?
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
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Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees.Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that
individual.
(B) Breakdown of W-2 and/or 1099-MISC compensation
(A) Name
(i) Base
compensation
(i)
1
EMPLOYEE A
(ii)
EMPLOYEE B
(ii)
EMPLOYEE C
(ii)
EMPLOYEE D
(ii)
EMPLOYEE E
(ii)
EMPLOYEE F
(ii)
(i)
(i)
(i)
(i)
(i)
230,000.
0
195,000.
0
180,000.
0
160,000.
0
160,000.
0
160,000.
0
10,000.
0
5,000.
0
0
0
0
0
0
0
0
0
(iii) Other
reportable
compensation
0
0
0
0
0
0
0
0
0
0
0
0
(D) Nontaxable
benefits
3,500.
3,500.
247,000.
2,500.
2,500.
205,000.
2,500.
2,500.
185,000.
1,500.
1,500.
163,000.
1,500.
1,500.
163,000.
1,500.
1,500.
163,000.
(F) Compensation
reported as deferred in
prior Form 990
(i)
7
(ii)
(ii)
(ii)
10
(ii)
11
(ii)
12
(ii)
13
(ii)
14
(ii)
15
(ii)
16
(ii)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
Schedule J (Form 990) 2011
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Page 3
DETERMINATION OF COMPENSATION
SCHEDULE J, PART I
THE ORGANIZATION USES A PERSONNEL COMMITTEE TO EVALUATE THE COMPENSATION
OF THE PRESIDENT OF THE ORGANIZATION WHO IS THE HIGHEST-RANKING EMPLOYEE.
THE
THE COMMITTEE
THE COMMITTEE
9:10:34 AM
V 11-4.1
EXEMPT ORGANIZATION
12-3456789
Page 3
9:10:34 AM
V 11-4.1
Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
Open to Public
Inspection
EXEMPT ORGANIZATION
Part I
Bond Issues
12-3456789
(c) CUSIP #
44-1234567
64922CU78
10/01/2003
(g) Defeased
Yes
No
(h) On
behalf of
issuer
(i) Pooled
financing
Yes
Yes
No
No
B
C
D
Part II
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Proceeds
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmm
mmmmm
Does the organization maintain adequate books and records to support the final allocation of proceeds?
Part III
2,700,000.
6,400,000.
2004
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
X
X
X
X
mmmmmmmmmmmmmmmmmmmmmmmmmmm
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
JSA
1E1295 1.000
9:10:34 AM
V 11-4.1
Yes
B
No
Yes
D
No
Yes
No
X
X
Schedule K (Form 990) 2011
EXEMPT ORGANIZATION
12-3456789
Page 2
Part III
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mm
mmmmmmm
I
mmmmmmmmm
I
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
m
mmmmmmmmmm
Yes
mmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmm
mm
mm
mm
mm
mm
mm
mm
m
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmm
mmmmmmmmmmmmmmmmmmm
Yes
3a Are there any management or service contracts that may result in private business
use of bond-financed property?
B
No
Yes
C
No
Yes
D
No
Yes
No
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel
to review any management or service contracts relating to the financed property?
c Are there any research agreements that may result in private business use of bond-
financed property?
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other
outside counsel to review any research agreements relating to the financed property?
4
6
7
Enter the percentage of financed property used in a private business use by entities
other than a section 501(c)(3) organization or a state or local government
%
%
%
%
%
%
%
%
Part IV
Arbitrage
A
Check the box if the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary
closing agreement program if self-remediation is not available under applicable regulations
X Yes
No
3a Has the organization or the governmental issuer entered into a qualified hedge with
respect to the bond issue?
b Name of provider
c Term of hedge
d Was the hedge superintegrated?
e Was the hedge terminated?
4a Were gross proceeds invested in a guaranteed investment contract (GIC)?
b Name of provider
c Term of GIC
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied?
5 Were any gross proceeds invested beyond an available temporary period?
6 Did the bond issue qualify for an exception to rebate?
Part V
Yes
No
Yes
D
No
Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of
Arbitrage Rebate, been filed with respect to the bond issue?
No
C
Yes
No
X
X
X
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
Part VI
Supplemental Information. Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
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SCHEDULE L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Name of the organization
Open To Public
Inspection
EXEMPT ORGANIZATION
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
12-3456789
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1
(c) Corrected?
Yes No
(1)
(2)
(3)
(4)
(5)
(6)
2
3
Enter the amount of tax imposed on the organization managers or disqualified persons during the year
under section 4958
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmI
Part II
$
$
To
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total
(c) Original
principal amount
From
Yes
No
by board or
committee?
agreement?
Yes
Yes
No
No
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
$
Part III
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person
organization
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
JSA
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EXEMPT ORGANIZATION
12-3456789
Page 2
Part IV
(c) Amount of
transaction
(e) Sharing of
organization's
revenues?
Yes
(1) TRUSTEE D
(2) EMPLOYEE X
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Part V
TRUSTEE OF ORGANIZATION
DAUGTER OF TRUSTEE
No
X
X
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
SCHEDULE L PART IV
NOTE 1
TRUSTEE D IS A BOARD MEMBER AND PARTNER IN A LAW FIRM PROVIDING LEGAL
SERVICES TO THE ORGANIZATION.
JSA
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SCHEDULE M
(Form 990)
Noncash Contributions
Open To Public
Inspection
Employer identification number
EXEMPT ORGANIZATION
Types of Property
Part I
12-3456789
(a)
Check if
applicable
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
mmmmmmmmmm
mmmmmm
mmmmmm
mmmmmm
mmmmmmmmmmmmmmmm
mmmmmm
mmmmmmmmmm
mmmmmmmm
mmmm
mmm
mmmmmmmmmm
mmmmm
(b)
Number of contributions or
items contributed
(c)
Noncash contribution
amounts reported on
Form 990, Part VIII, line 1g
I
I
I
I
(d)
Method of determining
noncash contribution amounts
FMV
mmmmmmmmmmmmm
mmmmmmmm
mmmmmm
mmmmm
mmmmmmmmm
mmmmmmmmmmmmm
mmmmmmmmmmm
mmmm
mmmmmmmmmmmmm
mmmmmmmmm
mmmmmmmm
mmmmmmm
mmmmmmmmm
29
Yes
30 a During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that
it must hold for at least three years from the date of the initial contribution, and which is not required to be
used for exempt purposes for the entire holding period?
b If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard
contributions?
32 a Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions?
b If "Yes," describe in Part II.
33
If the organization did not report an amount in column (c) for a type of property for which column (a) is checked,
describe in Part II.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
JSA
1E1298 1.000
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V 11-4.1
30a
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
31
32a
No
X
X
EXEMPT ORGANIZATION
Part II
12-3456789
Page 2
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b, 32b,
and 33. Also complete this part for any additional information.
JSA
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V 11-4.1
SCHEDULE O
(Form 990 or 990-EZ)
Open to Public
Inspection
EXEMPT ORGANIZATION
12-3456789
ACCOUNTANTS ASSISTS IN THE PREPARATION OF THE FORM 990 AND THEN IT GOES
THROUGH A REVIEW PROCESS TO ENSURE IT IS COMPLETED ACCURATELY.
THE FINAL DRAFT FORM 990 IS RETURNED TO THE ORGANIZATION WHERE SENIOR
EXECUTIVE MANAGEMENT AND MEMBERS OF THE FINANCIAL TEAM REVIEW THE
DOCUMENT.
THE AUDIT
COMMITTEE MEETS AND APPROVES THE FORM 990. PRIOR TO FILING, THE APPROVED
DRAFT RETURN IS CIRCULATED TO THE BOARD OF TRUSTEES.
THE AUDIT FIRM THEN ELECTRONICALLY FILES THE FINAL INFORMATIONAL RETURN
WITH THE IRS.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
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Page 2
EXEMPT ORGANIZATION
12-3456789
LINE 12C
IN ADDITION TO THE
FOR
THE CHAIR OF THE BOARD OF TRUSTEES WILL REPORT TO THE BOARD AND THE CHAIR
OF THE AUDIT COMMITTEE WILL REPORT TO THE AUDIT COMMITTEE OF THE BOARD AT
LEAST ONCE ANNUALLY CONCERNING ANY DISCLOSURES OF POTENTIAL CONFLICTS OF
INTEREST MADE TO THEM, AND ANY OTHER CONFLICTS-OF-INTERESTS, WHICH HAVE
OCCURRED.
JSA
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Page 2
EXEMPT ORGANIZATION
12-3456789
1. ANNUAL REPORT
$158,000
TOTAL
$188,000
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V 11-4.1
EXEMPT ORGANIZATION
SCHEDULE R
(Form 990)
12-3456789
OMB No. 1545-0047
Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
Open to Public
Inspection
EXEMPT ORGANIZATION
12-3456789
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
Part I
(a)
Name, address, and EIN of disregarded entity
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Total income
(e)
End-of-year assets
(f)
Direct controlling
entity
(1)
(2)
(3)
(4)
(5)
(6)
Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had
one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))
(f)
Direct controlling
entity
(g)
Section 512(b)(13)
controlled
entity?
Yes
(1) EXEMPT ORG 2
STREET
(2)
ADVOCACY ORG
STREET
No
13-1234567
NEW YORK, NY 10017
SHARED SRV
NY
ADVOCACY
NY
59(A)(3)
501(C)3
EXEMPT ORG
501(C)(4)
EXEMPT ORG
14-1234567
NEW YORK, NY 10017
(3)
(4)
(5)
(6)
(7)
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
JSA
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EXEMPT ORGANIZATION
12-3456789
Page 2
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34
because it had one or more related organizations treated as a partnership during the tax year.)
Part III
(a)
Name, address, and EIN
of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or
foreign
country)
(d)
Direct controlling
entity
(e)
Predominant
income (related,
unrelated,
excluded from
tax under
sections 512-514)
(f)
Share of total
income
(g)
Share of end-of-year
assets
(h)
Disproportionate
allocations?
(i)
Code V-UBI
amount in box 20
of
Schedule K-1
(Form 1065)
Yes No
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes No
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV,
line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
Part IV
(a)
Name, address, and EIN of related organization
(b)
Primary activity
(c)
Legal domicile
(state or
foreign country)
(d)
Direct controlling
entity
(e)
Type of entity
(C corp, S corp,
or trust)
(f)
Share of total
income
(g)
Share of
end-of-year assets
(h)
Percentage
ownership
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Schedule R (Form 990) 2011
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EXEMPT ORGANIZATION
12-3456789
Part V
Page
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35, 35a, or 36.)
Yes
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
1
During the tax year, did the organization engage in any of the following transactions with one or more related organizations listed in Parts IIIV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity
b Gift, grant, or capital contribution to related organization(s)
c Gift, grant, or capital contribution from related organization(s)
d Loans or loan guarantees to or for related organization(s)
e Loans or loan guarantees by related organization(s)
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
m
No
1a
1b
1c
1d
1e
X
X
X
X
X
f
g
h
i
1f
1g
1h
1i
X
X
X
X
j
k
l
m
n
1j
1k
1l
1m
1n
X
X
X
o
p
1o
1p
X
X
q
r
X
X
(a)
Name of other organization
(b)
Transaction
type (ar)
(c)
Amount involved
(1)
EXEMPT ORGANIZATION 2
M,N
175,000.
(2)
ADVOCACY ORGANIZATION
M,N
50,000.
X
X
(d)
Method of determining
amount involved
FMV
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2011
JSA
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EXEMPT ORGANIZATION
12-3456789
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets
or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity
(b)
Primary activity
(c)
Legal domicile
(state or foreign
country)
(d)
Predominant
income (related,
unrelated, excluded
from tax under
section 512-514)
(e)
Are all partners
section
501(c)(3)
organizations?
Yes
No
(f)
Share of
total income
(g)
Share of
end-of-year
assets
(h)
Disproportionate
allocations?
Yes
No
(i)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
Yes
(k)
Percentage
ownership
No
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
Schedule R (Form 990) 2011
JSA
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EXEMPT ORGANIZATION
12-3456789
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see
instructions).
9:10:34 AM
V 11-4.1