Part I

Form 990 Return of Organization Exempt From Income Tax

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

benefit trust or private foundation)

Department of the Treasury

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

For the 2004 calendar year, or tax year beginning , 2004, and ending , 

Name of organization D Employer identif

Please

use IRS

label or

print or

type.

See

Specific

Instructions.

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

City or town, state or country, and ZIP + 4

Check here  if the organization’s gross receipts are normally not more than $25,000. The

organization need not file a return with the IRS; but if the organization received a Form 990 Package

in the mail, it should file a return without financial data. Some states require a complete return.

Revenue, Expenses, and Changes in Net Assets or Fund Balances (See page 18 of the in

1 Contributions, gifts, grants, and similar amounts received:

a Direct public support 1a

b Indirect public support 1b

c Government contributions (grants) 1c

d Total (add lines 1a through 1c) (cash $ noncash $ ) 1d

2 Program service revenue including government fees and contracts (from Part VII, line 93) 2

3 Membership dues and assessments 3

4 Interest on savings and temporary cash investments 4

5 Dividends and interest from securities 5

6a Gross rents 6a

b Less: rental expenses 6b

c Net rental income or (loss) (subtract line 6b from line 6a) 6c

7 Other investment income (describe  ) 7

(A) Securities (B) Other Gross amount from sales of assets other

than inventory

8a

8a

Revenue

b Less: cost or other basis and sales expenses 8b

c Gain or (loss) (attach schedule) 8c

d Net gain or (loss) (combine line 8c, columns (A) and (B)) 8d

9

Gross revenue (not including $ of

contributions reported on line 1a)

a

9a

b Less: direct expenses other than fundraising expenses 9b

c Net income or (loss) from special events (subtract line 9b from line 9a) 9c

10a Gross sales of inventory, less returns and allowances 10a

b Less: cost of goods sold 10b

c Gross profit or (loss) from sales of inventory (attach schedule) (subtract line 10b from line 10a) 10c

11 Other revenue (from Part VII, line 103) 11

12 Total revenue (add lines 1d, 2, 3, 4, 5, 6c, 7, 8d, 9c, 10c, and 11) 12

13 Program services (from line 44, column (B)) 13

14 Management and general (from line 44, column (C)) 14

15 Fundraising (from line 44, column (D)) 15

Expenses

16 Payments to affiliates (attach schedule) 16

17 Total expenses (add lines 16 and 44, column (A)) 17

18 Excess or (deficit) for the year (subtract line 17 from line 12) 18

19 Net assets or fund balances at beginning of year (from line 73, column (A)) 19

Net Assets

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

21 Net assets or fund balances at end of year (combine lines 18, 19, and 20) 21

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 11282Y 

A

C

Room/suite

F Accounting method:

K

B Check if applicable:

Final return

Amended return

Address change

Organization type (check only one) 

G

I Group Exemption Number 

501(c) ( ) 4947(a)(1) or 527

H(a) Is this a group return for affiliat

If “Yes,” enter number of affilia

Is this a separate return filed by a

organization covered by a group r

H(b)

H(d)

(insert no.)

Initial return

Name change

Are all affiliates included?

(If “No,” attach a list. See instr

H(c) 

H and I are not applicable to section 

● Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable

trusts must attach a completed Schedule A (Form 990 or 990-EZ).

O

Check  if the organ

to attach Sch. B (Form 990, 

M

( )

Application pending

Other (specif

Website: 

L Gross receipts: Add lines 6b, 8b, 9b, and 10b to line 12 

J

Special events and activities (attach schedule). If any amount is from gaming, check here 
Form 990 (2004) 

Statement of

Functional Expenses

All organizations must complete column (A). Columns (B), (C), and (D) are required for section 501(c

and section 4947(a)(1) nonexempt charitable trusts but optional for others. (See page 22 of the inst

Do not include amounts reported on line

6b, 8b, 9b, 10b, or 16 of Part I.

(C) Management

and general

(B) Program

services (A) Total 

22 Grants and allocations (attach schedule)

23 Specific assistance to individuals (attach schedule)

24 Benefits paid to or for members (attach schedule)

25 Compensation of officers, directors, etc.

26 Other salaries and wages

27 Pension plan contributions

28 Other employee benefits

29 Payroll taxes

30 Professional fundraising fees

31 Accounting fees

32 Legal fees

33 Supplies

34 Telephone 

35 Postage and shipping

36 Occupancy

37 Equipment rental and maintenance

38 Printing and publications

39 Travel

40 Conferences, conventions, and meetings

41 Interest 

42 Depreciation, depletion, etc. (attach schedule)

43 Other expenses not covered above (itemize): a

b

c

d

e

Total functional expenses (add lines 22 through 43). Organizations

completing columns (B)-(D), carry these totals to lines 13—15

44

Statement of Program Service Accomplishments (See page 25 of the instructions.)

What is the organization’s primary exempt purpose? 

(Grants and allocations $ )

Other program services (attach schedule)

Total of Program Service Expenses (should equal line 44, column (B), Program services) 

Part III

Part II

If “Yes,” enter (i) the aggregate amount of these joint costs $ ; (ii) the amount allocated to Program service

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43a

44

43b

43c

43d

43e

Joint Costs. Check  if you are following SOP 98-2.

(cash $ noncash $ )

All organizations must describe their exempt purpose achievements in a clear and concise manner. State the number

of clients served, publications issued, etc. Discuss achievements that are not measurable. (Section 501(c)(3) and (4)

organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of grants and allocations to others.)

(iii) the amount allocated to Management and general $ ; and (iv) the amount allocated to Fundraising $

a

b

c

d

e

f

(Grants and allocations $ )

(Grants and allocations $ )

(Grants and allocations $ )

(Grants and allocations $ )

Are any joint costs from a combined educational campaign and fundraising solicitation reported in (B) Program services? 
Form 990 (2004) 

Balance Sheets (See page 25 of the instructions.)

(A)

Beginning of year

Note: Where required, attached schedules and amounts within the description

column should be for end-of-year amounts only.

Assets

45 Cash—non-interest-bearing 45

46 Savings and temporary cash investments 46

47a Accounts receivable 47a

b Less: allowance for doubtful accounts 47b 47c

48a Pledges receivable 48a

b Less: allowance for doubtful accounts 48b 48c

49 Grants receivable 49

50 Receivables from officers, directors, trustees, and key employees

(attach schedule) 50

51a

51a Other notes and loans receivable (attach

schedule)

b Less: allowance for doubtful accounts 51b 51c

52 Inventories for sale or use 52

53 Prepaid expenses and deferred charges 53

54 Investments—securities (attach schedule)  54

Investments—land, buildings, and

equipment: basis

55a

55a

Less: accumulated depreciation (attach

schedule)

b

55b 55c

56 Investments—other (attach schedule) 56

57a Land, buildings, and equipment: basis 57a

57b 57c

Less: accumulated depreciation (attach

schedule)

b

58 Other assets (describe  ) 58

59 Total assets (add lines 45 through 58) (must equal line 74) 59

Liabilities

60 Accounts payable and accrued expenses 60

61 Grants payable 61

62 Deferred revenue 62

63

Loans from officers, directors, trustees, and key employees (attach

schedule)

63

64a Tax-exempt bond liabilities (attach schedule) 64a

65 Other liabilities (describe  ) 65

66 Total liabilities (add lines 60 through 65) 66

Part IV

b Mortgages and other notes payable (attach schedule) 64b

Net Assets or Fund Balances Organizations that do not follow SFAS 117, check here 

67 Unrestricted 67

68 Temporarily restricted 68

69 Permanently restricted 69

70 Capital stock, trust principal, or current funds 70

71 Paid-in or capital surplus, or land, building, and equipment fund 71

72 Retained earnings, endowment, accumulated income, or other funds 72

73

73 Total net assets or fund balances (add lines 67 through 69 or lines

70 through 72;

column (A) must equal line 19; column (B) must equal line 21)

74 Total liabilities and net assets / fund balances (add lines 66 and 73) 74

and

Organizations that follow SFAS 117, check here  and complete lines

67 through 69 and lines 73 and 74.

complete lines 70 through 74.

Form 990 is available for public inspection and, for some people, serves as the primary or sole source of in

particular organization. How the public perceives an organization in such cases may be determined by the info

on its return. Therefore, please make sure the return is complete and accurate and fully describes, in Part III, 

programs and accomplishments.

Cost FMV
Form 990 (2004) 

List of Officers, Directors, Trustees, and Key Employees (List each one even if not compensat

the instructions.)

(B) Title and average hours per

week devoted to position

(C) Compensation

(If not paid, enter

-0-.)

(D) Contributions to

employee benefit plans 

deferred compensatio

(A) Name and address

Part V

Did any officer, director, trustee, or key employee receive aggregate compensation of more than $100,000 from your

organization and all related organizations, of which more than $10,000 was provided by the related organizations? 

If “Yes,” attach schedule—see page 28 of the instructions.

Reconciliation of Revenue per Audited

Financial Statements with Revenue per

Return (See page 27 of the instructions.)

a

b

c

d

e

(1)

(2)

(3)

Reconciliation of Expenses p

Financial Statements with Ex

Return

(4)

(1)

(2)

a

b

c

d

e

(1)

(2)

(3)

(4)

(1)

(2)

Part IV-A Part IV-B

75

Total revenue, gains, and other support

per audited financial statements 

Amounts included on line a but not on

line 12, Form 990:

Net unrealized gains

on investments

Donated services

and use of facilities

Recoveries of prior

year grants

Other (specify):

Add amounts on lines (1) through (4) 

Line a minus line b 

Amounts included on line 12,

Form 990 but not on line a:

Investment expenses

not included on line

6b, Form 990

Other (specify):

Add amounts on lines (1) and (2) 

Total revenue per line 12, Form 990

(line c plus line d) 

a

b

c

d

e

$

$

$

$

$

$

Total expenses and losses per

audited financial statements 

Amounts included on line a but not

on line 17, Form 990:

Donated services

and use of facilities

Prior year adjustments

reported on line 20,

Form 990

Losses reported on

line 20, Form 990

Other (specify):

Add amounts on lines (1) through (4)

Line a minus line b 

Amounts included on line 17,

Form 990 but not on line a:

Investment expenses

not included on line

6b, Form 990

Other (specify):

Add amounts on lines (1) and (2) 

Total expenses per line 17, Form 990

(line c plus line d) 

$

$

$

$

$

$
Form 990 (2004) 

Other Information (See page 28 of the instructions.)

76 Did the organization engage in any activity not previously reported to the IRS? If “Yes,” attach a detailed description of each activity 

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

If “Yes,” attach a conformed copy of the changes.

78a Did the organization have unrelated business gross income of $1,000 or more during the year covered by this return? 

b If “Yes,” has it filed a tax return on Form 990-T for this year? 

At any time during the year, did the organization own a 50% or greater interest in a taxable corporation or

partnership, or an entity disregarded as separate from the organization under Regulations sections

301.7701-2 and 301.7701-3? If “Yes,” complete Part IX

79 Was there a liquidation, dissolution, termination, or substantial contraction during the year? If “Yes,” attach a statement 

Is the organization related (other than by association with a statewide or nationwide organization) through common

membership, governing bodies, trustees, officers, etc., to any other exempt or nonexempt organization?

80a

If “Yes,” enter the name of the organization 

and check whether it is exempt or nonexempt.

b

81a Enter direct and indirect political expenditures. See line 81 instructions 81a

b Did the organization file Form 1120-POL for this year? 

Did the organization receive donated services or the use of materials, equipment, or facilities at no charge

or at substantially less than fair rental value?

82a

If “Yes,” you may indicate the value of these items here. Do not include this amount

as revenue in Part I or as an expense in Part II. (See instructions in Part III.)

b

82b

83a Did the organization comply with the public inspection requirements for returns and exemption applications? 

84a Did the organization solicit any contributions or gifts that were not tax deductible? 

If “Yes,” did the organization include with every solicitation an express statement that such contributions

or gifts were not tax deductible?

b

85 501(c)(4), (5), or (6) organizations. a Were substantially all dues nondeductible by members? 

b Did the organization make only in-house lobbying expenditures of $2,000 or less?

86 501(c)(7) orgs. Enter: a Initiation fees and capital contributions included on line 12

b Gross receipts, included on line 12, for public use of club facilities

87 501(c)(12) orgs. Enter: a Gross income from members or shareholders 87a

Gross income from other sources. (Do not net amounts due or paid to other

sources against amounts due or received from them.)

b

87b

88

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

90a

91

Located at  

92 Section 4947(a)(1) nonexempt charitable trusts filing Form 990 in lieu of Form 1041—Check here 

and enter the amount of tax-exempt interest received or accrued during the tax year  92

Part VI 

c Dues, assessments, and similar amounts from members 85c

d Section 162(e) lobbying and political expenditures 85d

e Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices 85e

f Taxable amount of lobbying and political expenditures (line 85d less 85e) 85f

g Does the organization elect to pay the section 6033(e) tax on the amount on line 85f?

h If section 6033(e)(1)(A) dues notices were sent, does the organization agree to add the amount on line 85f to its

reasonable estimate of dues allocable to nondeductible lobbying and political expenditures for the following tax

year?

86a

86b

If “Yes” was answered to either 85a or 85b, do not complete 85c through 85h below unless the organization

received a waiver for proxy tax owed for the prior year.

ZIP + 4 

b Did the organization comply with the disclosure requirements relating to quid pro quo contributions? 

The books are in care of  Telephone no.  ( )

501(c)(3) organizations. Enter: Amount of tax imposed on the organization during the year under:

; section 4912  ; section 4955 

501(c)(3) and 501(c)(4) orgs. Did the organization engage in any section 4958 excess benefit transaction

during the year or did it become aware of an excess benefit transaction from a prior year? If “Yes,” attach

a statement explaining each transaction

Enter: Amount of tax imposed on the organization managers or disqualified persons during the year under

sections 4912, 4955, and 4958 

89a

b

c

section 4911 

d Enter: Amount of tax on line 89c, above, reimbursed by the organization 

b Number of employees employed in the pay period that includes March 12, 2004 (See instructions.) 90b
Form 990 (2004) 

Analysis of Income-Producing Activities (See page 33 of the instructions.)

Excluded by section 512, 513, or 51

Note: Unrelated business income Enter gross amounts unless otherwise

indicated. (C)

Exclusion code

(B)

Amount

(D)

Amount

(A)

Business code 93 Program service revenue:

a

b

c

d

e

f

Fees and contracts from government agencies

94 Membership dues and assessments

95 Interest on savings and temporary cash investments

96 Dividends and interest from securities

97 Net rental income or (loss) from real estate:

debt-financed property

not debt-financed property

98 Net rental income or (loss) from personal property

99 Other investment income

100 Gain or (loss) from sales of assets other than inventory

101 Net income or (loss) from special events

102 Gross profit or (loss) from sales of inventory

103 Other revenue: a

b

c

d

e

104 Subtotal (add columns (B), (D), and (E))

105 Total (add line 104, columns (B), (D), and (E)) 

Note: Line 105 plus line 1d, Part I, should equal the amount on line 12, Part I.

Relationship of Activities to the Accomplishment of Exempt Purposes (See page 34 of the 

Explain how each activity for which income is reported in column (E) of Part VII contributed importantly to the 

of the organization’s exempt purposes (other than by providing funds for such purposes).

Line No.



Information Regarding Taxable Subsidiaries and Disregarded Entities (See page 34 of the inst

(D)

Total income

(C)

Nature of activities

(B)

Percentage of

ownership interest

(A)

Name, address, and EIN of corporation,

partnership, or disregarded entity

Part IX

Part VIII

Part VII

a

b

g

%

%

%

%

Medicare/Medicaid payments

Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?

Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?

(b)

(a)

Part X Information Regarding Transfers Associated with Personal Benefit Contracts (See page 34 of the i

Note: If “ Yes” to (b), file Form 8870 and Form 4720 (see instructions).

Date

EIN 

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to th

and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which prepa

Please

Sign

Here

Type or print name and title.

Signature of officer Date

Preparer’s

signature

Check if

selfemployed 

Paid

Preparer’s

Use Only Firm’s name (or yours

if self-employed),

address, and ZIP + 4

Preparer’s SSN 

Phone no.  ( )