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Form 990: Return of Organization Exempt From Income Tax

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Return of Organization Exempt From Income Tax
Check if applicable:










$

H(a) Is this a group return for subordinates?
H(b) Are all subordinates included?
If “No,” attach a list. (see instructions)
Tax-exempt status:
Form of organization:
Part I Summary
Activities
&
Governance
1
2
33
44
55
66
7a7a
b7b
RevenuePrior YearCurrent Year
8
9
10
11
12
Expenses13
14
15
16a
b
17
18
19
Net
Assets
or
Fund
Balances
Beginning of Current YearEnd of Year
20
21
22
Part II Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign
Here



Paid
Preparer
Use Only




May the IRS discuss this return with the preparer shown above? (see instructions)  
Part III Statement of Program Service Accomplishments
1
2 Yes   No
3 Yes   No
If “Yes,” describe these changes on Schedule O.
4
4a$ $ $
4b$ $ $
4c$ $ $
4dOther program services (Describe in Schedule O.)
$ $ $
4e
Part IV Checklist of Required Schedules
YesNo
11
22
33
44
55
66
77
88
99
1010
11
a11a
b11b
c11c
d11d
e11e
f11f
12a12a
b12b
1313
14a14a
b14b
1515
1616
1717
1818
1919
Part IV Checklist of Required Schedules (continued)
20a20a
b20b
2121
2222
2323
24a24a
b24b
c24c
d24d
25a25a
b25b
2626
2726
28
a28a
b28b
c28c
2929
3030
3131
3232
3333
3434
35a35a
b35b
3636
3737
3838
Part V Statements Regarding Other IRS Filings and Tax Compliance
YesNo
1a1a
b1b
c1c
2a2a
b
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
3a3a
b3b
4a4a
b
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
5a5a
b5b
c5c
6a6a
b6b
7
a7a
b7b
c7c
d7d
e7e
f7f
g7g
h7h
88
9
a9a
b9b
10
a10a
b10b
11
a11a
b11b
12a12a
b12b
13
a
Note. See the instructions for additional information the organization must report on Schedule O.
13a
b13b
c13c
14a14a
b14b
Part VI 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.
Section A. Governing Body and Management
YesNo
1a
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
b1b
22
33
44
55
66
7a7a
b7b
8
a8a
b8b
99
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
YesNo
10a10a
b10b
11a11a
b
12a12a
b12b
c12c
1313
1414
15
a15a
b
If “Yes” to line 15a or 15b, describe the process in Schedule O (see instructions).
15b
16a16a
b16b
Section C. Disclosure
17
18Section 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.
19Describe 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.
20
Part VII Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
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 $100000 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 $100000 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 $100000 of reportable compensation from the organization and any related organizations.
List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest compensated employees; and former such persons.

Name and Title

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

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

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

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

Estimated
amount of
other
compensation
from the
organization
and related
organizations
Individual
trustee
or
director
Institutional
trustee
OfficerKey
employee
Highest
compensated
employee
Former


















































1b
c
d
2
YesNo
33
44
55
Section B. Independent Contractors
1Complete 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.

Name and business address

Description of services

Compensation
2
Part VIII Statement of Revenue

Total revenue

Related or
exempt
function
revenue

Unrelated
business
revenue

Revenue
excluded
from
tax
under
sections
512-514
Contributions,
Gifts,
Grants
and
Other
Similar
Amounts
1a1a
b1b
c1c
d1d
e1e
f1f
g $
h
Program
Service
Revenue
Business Code
2a
b
c
d
e
f
g
Other
Revenue
3
4
5
(i) Real(ii) Personal
6a
b
c
d
(i) Securities(ii) Other
7a
b
c
d
8a $ a
bb
c
9aa
bb
c
10aa
bb
c
Miscellaneous RevenueBusiness Code
11a
b
c
d
e
12
Part IX Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A)
Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII
Total expenses

Program service
expenses

Management
and general
expenses

Fundraising
expenses
1
2
3
4
5
6
7
8
9
10
11
a
b
c
d
e
f
g
12
13
14
15
16
17
18
19
20
21
22
23
24
a
b
c
d
e
25
26
Part X Balance Sheet

Beginning of year

End of year
Assets11
22
33
44
55
66
77
88
99
10a10a
b10b10c
1111
1212
1313
1414
1515
1616
Liabilities1717
1818
1919
2020
2121
2222
2323
2424
2525
2626
Net
Assets
or Fund
Balances
2727
2828
2929
3030
3131
3232
3333
3434
Part XI Reconciliation of Net Assets
11
22
33
44
55
66
77
88
99
1010
Part XII Financial Statements and Reporting
YesNo
1Accounting method used to prepare the Form 990: If the organization changed its method of accounting from a prior year or checked “Other,” explain in Schedule O.
2a2a
If “Yes,” check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b2b
If “Yes,” check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c2c
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a3a
b3b

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