D Employer iden

E Telephone nu

Group Exemp

Number 

F

Organization type (check only one)—

Short Form 

Return of Organization Exempt From Income Tax

O

Form 990-EZ 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

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

Please Name of organization

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)

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

Revenue, Expenses, and Changes in Net Assets or Fund Balances (See page 37 of the in

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

2 Program service revenue including government fees and contracts 2

3 Membership dues and assessments 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) from sale of assets other than inventory (line 5a less line 5b) (attach schedule) 5c

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

a Gross revenue (not including $ of contributions

Revenue

reported on line 1) 6a

b 6b

c Net income or (loss) from special events and activities (line 6a less line 6b) 6c

7a Gross sales of inventory, less returns and allowances 7a

b Less: cost of goods sold 7b

c Gross profit or (loss) from sales of inventory (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 Assets

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

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

(A) Beginning of year 

22 Cash, savings, and investments 22

23 Land and buildings 23

24 Other assets (describe  ) 24

25 Total assets 25

26 26

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

For Privacy Act and Paperwork Reduction Act Notice, see 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.

Check  if the organization’s gross receipts are normally not more than $25,000. The organization need not file a return w

organization received a Form 990 Package in the mail, it should file a return without financial data. Some states require a co

Op

C

Part II

Part I

Room/suite

Accounting method:

I

J

Less: direct expenses other than fundraising expenses

Total liabilities (describe  )

Cat. No. 10642I 

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

● Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach G

B Check if applicable:

Initial return

Final return

Amended return

Address change

(See page 40 of the instructions.)

501(c) ( )  (insert no.) 527 4947(a)(1) or

Other (specify) 

( )

Name change

K

L Add lines 5b, 6b, and 7b, to line 9 to determine gross receipts; if $100,000 or more, file Form 990 instead of Form 990-EZ  $

Check  if the o

is not required to attac

Schedule B (Form 990

Application pending

Website: 

H

a completed Schedule A (Form 990 or 990-EZ).
Form 990-EZ (2004) 

Statement of Program Service Accomplishments (See page 41 of the instructions.) 

Describe what was achieved in carrying out the organization’s exempt purposes. In a clear and concise manner,

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 28a through 31a) 

List of Officers, Directors, Trustees, and Key Employees (List each one even if not compensated. See page 41 of 

(C) Compensation

(If not paid,

enter -0-.)

(D) Contributions to

employee benefit plan

deferred compensatio

(B) Title and average

hours per week

devoted to position

(A) Name and address

Other Information (Note the attachment requirement in General Instruction V, page 14.) 

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

34 Were any changes made to the organizing or governing documents but not reported to the IRS? If “Yes,” attach a conformed copy of the c

If the organization had income from business activities, such as those reported on lines 2, 6, and 7 (among other

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

35

a Did the organization have unrelated business gross income of $1,000 or more or 6033(e) notice, reporting, and proxy tax require

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

36 Was there a liquidation, dissolution, termination, or substantial contraction during the year? (If “Yes,” attach a state

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

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

Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or we

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 line 38 instructions and enter the amount involved. 38b

39 501(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 39b

42 The books are in care of  Telephone no. 

Located at 

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

43

Date

EIN 

( 

Part V

Part IV

Part III

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

(R

an

an

o

ZIP + 4 

Preparer’s S

Phone no.  ( 

What is the organization’s primary exempt purpose?

28

29

30

31

32

38a

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

section 4911  ; section 4912  ; section 4955 

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

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

Amount of tax imposed on organization managers or disqualified persons during the year under 4912, 4955, and 4958 

40a

b

c

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

d Enter: Amount of tax on line 40c, above, reimbursed by the organization 









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

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

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