OMB No. 1545-0047

SCHEDULE G

Department of the Treasury

Internal Revenue Service

Name of the organization Employer identification number

Fundraising Activities. Complete if the organization answered “Yes” to Form 990, Part IV, line 17.

Form 990-EZ filers are not required to complete this part.

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule G (Form 990 or 990-EZ) 2009

Part I

Cat. No. 50083H

(Form 990 or 990-EZ)

Supplemental Information Regarding

Fundraising or Gaming Activities

1

3

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from

registration or licensing.

Mail solicitations

Internet and email solicitations

Phone solicitations

Solicitation of non-government grants

Solicitation of government grants

Special fundraising events

2a

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.

Yes No

(ii) Activity (vi) Amount paid to

(or retained by)

organization

(iv) Gross receipts

from activity

(i) Name of individual

or entity (fundraiser)

Total ©

(v) Amount paid to

(or retained by)

fundraiser listed in

col. (i)

Open To Public

Inspection

2009

In-person solicitations

(iii) Did fundraiser have

custody or control of

contributions?

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?

b

Yes No

a

b

c

d

e

f

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.
Schedule G (Form 990 or 990-EZ) 2009 Page 2

9 Enter the state(s) in which the organization operates gaming activities:

a Is the organization licensed to operate gaming activities in each of these states?

b If “No,” explain:

10a Were any of the organization’s gaming licenses revoked, suspended or terminated during the tax year?

11 Does the organization operate gaming activities with nonmembers?

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming?

11

Gaming. Complete if the organization answered “Yes” to Form 990, Part IV, line 19, or reported more

than $15,000 on Form 990-EZ, line 6a.

Part III

(b) Pull tabs/instant

bingo/progressive bingo

(a) Bingo (c) Other gaming

Net gaming income summary. Combine line 1, column d, and line 7 ©

(d) Total gaming (add

col. (a) through col. (c))

1

2

3

4

5

6

7

8

Direct Expenses

Part III

Gross revenue 

Cash prizes 

Noncash prizes 

Rent/facility costs 

Other direct expenses 

Volunteer labor 

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

Yes

No

% Yes

No

% Yes

No

%

Yes No

b If “Yes,” explain:

12

12Revenue

9a

10a

Fundraising Events. Complete if the organization answered “Yes” to Form 990, Part IV, line 18, or reported

more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.

Part II

(a) Event #1 (b) Event #2 (c) Other events

Direct expense summary. Add lines 4 through 9 in column (d) ©

(d) Total events

(add col. (a) through

col. (c))

1

2

3

4

5

6

9

10

(event type) (event type) (total number)

Direct Expenses

Gross receipts 

Less: Charitable

contributions

Gross income (line 1

minus line 2) 

Cash prizes 

Noncash prizes 

Rent/facility costs 

Other direct expenses 

11 Net income summary. Combine line 3, column (d), and line 10 ©

Revenue

( )

( )

7 Food and beverages 

8 Entertainment 
Schedule G (Form 990 or 990-EZ) 2009 Page 3

Schedule G (Form 990 or 990-EZ) 2009

17 Mandatory distributions:

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 © $

Yes No

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license?

a

16 Gaming manager information:

Name ©

Gaming manager compensation © $

Description of services provided ©

Director/officer Employee Independent contractor

b

17a

13a

13b

13 Indicate the percentage of gaming activity operated in:

a

b

The organization’s facility

An outside facility

%

%

14 Enter the name and address of the person who prepares the organization’s gaming/special events books

and records:

15a Does the organization have a contract with a third party from whom the organization receives gaming

revenue?

b If “Yes,” enter the amount of gaming revenue received by the organization © $ and the

amount of gaming revenue retained by the third party © $ .

Name ©

Address ©

If “Yes,” enter name and address of the third party:

Address ©

c

15a

Name ©