C Employer identification number

D State registration number

Enter four-digit group exemption

number (GEN)

E

Check type of organization—Exempt under section © 501(c) ( ) (insert number), OR © section 4947(a)(1) trust

Accounting method: Cash Accrual Other (specify) ©

Enter your 1991 gross receipts (add back lines 5b, 6b, and 7b, to line 9) © $

Check © if address changed.

Short Form 

Return of Organization Exempt From Income Tax

OMB No. 1545-1150

Form 990EZ Under section 501(c) of the Internal Revenue Code (except black lung benefit trust or

private foundation) or section 4947(a)(1) charitable trust

Department of the Treasury

Internal Revenue Service

A For the calendar year 1991, or fiscal year beginning , 1991, and ending , 19

Please Name of organization

use IRS

label or

print or

type.

See

Specific

Instructions.

Number and street (or P.O. box no., if mail is not delivered to street address)

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

Statement of Revenue, Expenses, and Changes in Net Assets or Fund Balances

1 Contributions, gifts, grants, and similar amounts received (attach schedule—see instructions) 1

2 Program service revenue 2

3 Membership dues and assessments (see instructions) 3

4 Investment income 4

5a Gross amount from sale of assets other than inventory 5a

b Less: cost or other basis and sales expenses 5b

c Gain or (loss) (line 5a less line 5b) (attach schedule) 5c

6 Special events and activities (attach schedule—see instructions):

a Gross revenue (not including $ of contributions

Revenue

reported on line 1) 6a

b 6b

c Net income or (loss) (line 6a less line 6b) 6c

7a Gross sales less returns and allowances 7a

b Less: cost of goods sold 7b

c Gross profit or (loss) (line 7a less line 7b) 7c

8 Other revenue (describe © ) 8

9 Total revenue (add lines 1, 2, 3, 4, 5c, 6c, 7c, and 8) © 9

10 Grants and similar amounts paid (attach schedule) 10

11 Benefits paid to or for members 11

12 Salaries, other compensation, and employee benefits 12

13 Professional fees and other payments to independent contractors 13

14 Occupancy, rent, utilities, and maintenance 14

Expenses

15 Printing, publications, postage, and shipping 15

16 Other expenses (describe © ) 16

17 Total expenses (add lines 10 through 16) © 17

18 Excess or (deficit) for the year (line 9 less line 17) 18

19 Net assets or fund balances at beginning of year (from line 27, column (A)) 

(must agree with end-of-year figure reported on prior year’s return) 19

20 Other changes in net assets or fund balances (attach explanation) 20

Net AssetsNet assets or fund balances at end of year (combine lines 18 through 20) 

(must agree with line 27, column (B)) ©

21

21

Balance Sheets—If Total assets on line 25, column (B) are $250,000 or more, you must file Form 990 instead of Form 990EZ.

(A) Beginning of year (B) End of year

22 Cash, savings, and investments 22

Land and buildings 23 23

24 Other assets (describe © ) 24

25 Total assets 25

26 26

27 Net assets or fund balances (column (B) must agree with line 21.) 27

For Paperwork Reduction Act Notice, see page 1 of the separate instructions.

© For organizations with gross receipts less than $100,000 and total assets less

than $250,000 at the end of the year.

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

Check © if your gross receipts are normally not more than $25,000. You need not file a completed return with IRS; but if you received a

Form 990 Package in the mail, you should file a return without financial data. Some states require a completed return.

This Form is

Open to Public

Inspection

B

Part II

Part I

Room/suite

Check © if exemption application pending.

I

G

F

H

J

If $100,000 or more, you must file Form 990 instead of Form 990EZ.

Less: direct expenses 

K

Total liabiities (describe © )

Cat. No. 10642I Form 990EZ (1991)
Form 990EZ (1991) Page 2

Statement of Program Service Accomplishments—(See instructions.) Expenses

Describe what was achieved in carrying out your exempt purposes. Fully describe the services provided, the

number of persons benefited, or other relevant information for each program title.

28

(Grants $ )

29

(Grants $ )

30

(Grants $ )

31 Other program services (attach schedule) (Grants $ )

32 Total program service expenses (add lines 28 through 31) ©

List of Officers, Directors, and Trustees (List each one even if not compensated. See instructions.)

(C) Compensation

(If not paid,

enter zero.)

(D) Contributions

to employee

benefit plans

(E) Expense

account and

other allowances

(B) Title and average

hours per week

devoted to position

(A) Name and address

Other Information—Section 501(c)(3) organizations and section 4947(a)(1) charitable trusts must

also complete and attach Schedule A (Form 990). (See instruction C1.) Yes No

33 Did the organization engage in any activity not previously reported to the Internal Revenue Service?

If ‘‘Yes,’’ attach a detailed description of each activity.

34 Were any changes made to the organizing or governing documents but not reported to IRS?

If ‘‘Yes,’’ attach a conformed copy of the changes.

If the organization had income from business activities, such as those reported on lines 2, 6, and 7 (among others), but NOT

reported on Form 990-T, attach a statement explaining your reason for not reporting the income on Form 990-T.

35

a Did the organization have unrelated business gross income of $1,000 or more during the year covered by this return?

b If ‘‘Yes,’’ have you filed a tax return on Form 990-T, Exempt Organization Business Income Tax Return, for this year?

36 Was there a liquidation, dissolution, termination, or substantial contraction during the year? (See instructions.)

If ‘‘Yes,’’ attach a statement as described in the instructions.

37a Enter amount of political expenditures, direct or indirect, as described in the instructions. © 37a

b Did you file Form 1120-POL, U.S. Income Tax Return for Certain Political Organizations, for this year?

38a Did you borrow from, or make any loans to, any officer, director, trustee, or key employee, OR were any such loans

made in a prior year and still unpaid at the start of the period covered by this return?

b If “Yes,” attach the schedule specified in the instructions and enter the amount involved 38b

39 Section 501(c)(7) organizations.—Enter:

a Initiation fees and capital contributions included on line 9 39a

b Gross receipts, included on line 9, for public use of club facilities (see instructions) 39b

Does the club’s governing instrument or any written policy statement provide for discrimination against any person

because of race, color, or religion? (See instructions.)

c

40 List the states with which a copy of this return is filed. ©

41 The books are in care of © Telephone no. ©

Located at ©

Section 4947(a)(1) charitable trusts filing Form 990EZ in lieu of Form 1041, U.S. Fiduciary Income Tax Return.—Check here ©

and enter the amount of tax-exempt interest received or accrued during the tax year ©

42

42

Date

ZIP code

( )

Part V

Part IV

Part III

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge Please 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 © Signature of officer Date Title

Preparer’s

signature

Check if selfemployed ©

Paid

Preparer’s

Use Only

Firm’s name (or

yours if self-employed)

and address

©

©

©

(Required for 501(c)(3) and (4)

organizations and 4947(a)(1)

trusts; optional for others.)