SCHEDULE G 

(Form 990 or 990-EZ)

Department of the Treasury 

Internal Revenue Service 

Supplemental Information Regarding Fundraising or Gaming Activities

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.

OMB No. 1545-0047

2011

Open to Public 

Inspection

Name of the organization Employer identification number

Part I 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.

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

a Mail solicitations

b Internet and email solicitations

c Phone solicitations

d In-person solicitations

e Solicitation of non-government grants

f Solicitation of government grants

g Special fundraising events

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? 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

(iii) Did fundraiser have

custody or control of

contributions?

(iv) Gross receipts

from activity

(v) Amount paid to

(or retained by)

fundraiser listed in

col. (i)

(vi) Amount paid to

(or retained by)

organization

 Yes No 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

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.

 Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Cat. No. 50083H Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011 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.

Revenue Direct Expenses 

(a) Event #1

(event type)

(b) Event #2

(event type)

(c) Other events

(total number)

(d) Total events

(add col. (a) through 

col. (c))

 

1 Gross receipts . . . .

2 Less: Charitable 

contributions . . . .

3 Gross income (line 1 minus 

line 2) . . . . . . .

4 Cash prizes . . . . .

5 Noncash prizes . . .

6 Rent/facility costs . . .

7 Food and beverages . .

8 Entertainment . . . .

9 Other direct expenses .

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

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

Part III 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.

Revenue Direct Expenses (a) Bingo (b) Pull tabs/instant

bingo/progressive bingo (c) Other gaming (d) Total gaming (add

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

1 Gross revenue . . . .

2 Cash prizes . . . . .

3 Noncash prizes . . .

4 Rent/facility costs . . .

5 Other direct expenses .

6 Volunteer labor . . . .

Yes %

No

Yes %

No

Yes %

No

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

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

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? . . . . . . . . . Yes No

b If “No,” explain:

10a Were any of the organization’s gaming licenses revoked, suspended or terminated during the tax year? . Yes No

b If “Yes,” explain:

Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011 Page 3

11 Does the organization operate gaming activities with nonmembers? . . . . . . . . . . . . . Yes No

12 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? . . . . . . . . . . . . . . . . . . . . . . Yes No

13 Indicate the percentage of gaming activity operated in:

a The organization’s facility . . . . . . . . . . . . . . . . . . . . . . . . . 13a %

b An outside facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13b %

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

records:

Name ▶

Address ▶

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

revenue? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

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:

Name ▶

Address ▶

16 Gaming manager information:

Name ▶

Gaming manager compensation ▶ $

Description of services provided ▶

Director/officer Employee Independent contractor

17 Mandatory distributions:

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

retain the state gaming license? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

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 ▶ $

Part IV Supplemental Information. Complete this part to provide the explanations 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).

Schedule G (Form 990 or 990-EZ) 2011