Return of Organization Exempt From Income Tax

Form 990 A (SF) Section 501(c)(3) of the Internal Revenue Code
For the calendar year 1969, or other taxable year beginning

Department of the Treasury i"
Internal Revenue Service = 1969, and ending .. 19.

If item 3 is more than $10,000 or if total assets at end of year are more than $10,000,
use Form 990-A (except if is a group return described in the instructions).

Name of organization Employer identification number
(See instructions)
Pleasetype, | _|
print or ‘Address (number and street)
attach label.
See instructions. | “City or town, State, and ZIP code Date of exemption letter

Enter the name and address used on your return for 1968 (if the same as above, write “Same"), If none filed give reason,

Gross Receipts
1 Principal (contributions, gifts, grants and similar amounts received). . . . . . . 1 1 we
2 Income (amounts received from all other sources) © © 2 6 ee ee ee ee ee ee J
3 Gross receipts (line 1 plus line2). 2. . 2. ee we ee
Expenses and Disbursements Attri utable to Pr nelpal
4 Expenses of raising and collecting amount onlinel . 6 2 ee ee
5 Disbursements out of principal for exempt purposes: (a) During the year. . . . . . . . __
(b) In prior years. «©. 1 1 we ee |
Costs and Expenses Attributable to Income
6 Cost of goods sold and/or of business operations. . . 1. 6 1 ee ee ee ee
7 Cost or other basis of assets sold and expense ofsale. © © 6... ee eee ee
8 Expenses of earning income reported on line 2 . . 6 1 1 ee ee ee ee |___.
9 Total of lines 6 through 8 6 we ee __
Accumulation of Income
10 Net income for the year (line 2lessline9). . . 6 6 ee ee ee ee —
11 Accumulation of income at beginning of year. . . - So |_
12 Disbursements out of current or accumulated income for exempt purposes . 2. . . 2. _
13 Accumulation of income at end of year (the sum of lines 10 and 11 less line 12) . . . . . . |
‘Assets Beginning of year End of year
Bi pcm
& | 2 supplies and equipment. © ©. 6 6 ee
8 3 Land and buildings. ©. - / ee ee ee ee ee
| 4 Investments © 2 6 ee ee
& | 5 Other (describe) .. fo
1 6 Total assets. 6 6 ee ee ee ee ee
wi jabilities and Net Worth
=| 7 Liabilities payable within one year.» 2.) 1 1 ee ee
| 8 Other liabilities © ©. 6 1 ee ee ee ee
3 | 9 Net worth or capital account. © 2 2 2... ee ee
a |10 Total liabilities and net worth. . 2. 1 ee ee ee
1 Describe your principal activites (attach statement if more space is needed).
2 During the year, did you: | Yes |_No
(a) Engage in any activities not in furtherance of your exempt purposes? If “Yes,” attach a detailed description of such activities. |__|
(b) Advocate or oppose any national, state, or local legislation? If “Yes,” attach a detailed description of such activities and copies
‘of any published or distributed statements —
(© Participate or intervene in any political campaign on’ behalf of, or in opposition to, any candidate for public office? If “Yes,”
attach a detailed description of such activities and copies of any published or distributed statements - |__|__
(@) Hold five percent or more of any class of stock in any corporation? If “Yes,” identify corporation and explain “relationship t6
your organization . . : : |—__}_
(e) Solicit contributions by mail appeal? If “Yes,” give estimated percentage of gross receipts attributable to this source ( .)
3 Have any changes not previously reported to the Internal Revenue Service been made in your articles of incorporation, or bylaws,
or other instruments of similar import? If “Yes,” attach a copy of the changes . . . . - - + « : on
4 Is this a group return filed on behalf of subordinates (who are covered by a group exemption letter)?» . :

Under penalties of perjury, 1 declare that | have exa
true, correct, and complete. If prepared by a person other than taxpayer, his declaration is based on all information of which he has any knowledge.

‘CORPORATE - =
SEAL Date ‘Signature of officer Title

obo—16—s08a7-1 «ate

ined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is



Instructions

An annual return, on Form 990-A (long form) or Form 990~A(SF) (short form) is required of
organizations exempt from tax under section 501(c)(3) of the Code (including cooperative hospital service
organizations described in section 501(e) of the Code), except: (a) a religious organization; (b) an educa-
tional organization if it normally maintains a regular faculty and curriculum and normally has a regularly
organized body of pupils or students in attendance at the place where its educational activities are regularly
carried on; (c) a charitable organization, or an organization for the prevention of cruelty to children or
animals, if supported in whole or in part by funds contributed by the United States or any State or political
subdivision thereof, or primarily supported (more than 50 percent) by contributions of the general public;
and (d) an organization operated, supervised, or controlled by or in connection with a religious organization

described in section 501(c)(3).

Who May File.—This short form return may be filed only by
an organization, which is exempt from tax under section 501
(©)(3) and whose gross receipts (defined below) for the year
and total assets at the end of the year do not exceed $10,000.

Gross Receipts For Purposes of This Return.—Gross receipts
mean the gross amount received by the organization during its
annual accounting period from all sources without reduction
for any costs or expenses; including for example—cost of goods
or assets sold, cost of operations, or expenses of earning, rais-
ing, or collecting such amounts. Thus, gross receipts includes
but is not limited to (a) the gross amount received as contribu-
tions, gifts, grants and similar amounts without reduction for
the expenses of raising and collecting such amounts (b) the
gross amount received as dues or assessments from members
or affiliated organizations without reduction for expenses attrib-
utable to the receipt of such amounts (c) gross sales or receipts
from business activities including business activities unrelated
to the purpose for which the organization received an exemp-
tion, the net income or loss from which may be required to be
reported on Form 990-T (see below) (d) the gross amount re-
ceived from the sale of assets without reduction for the cost or
other basis of the property and expense of sale; and (e) the
gross amount received as investment income such as interest,
dividends, rents and royalties.

Distributions Paid.—lf you paid out contributions, gifts,
grants, scholarships, or other distributions of $1,000 or more
on behalf of any one donee, attach a separate schedule listing
the name and address of such donee, the amount of the distri-
bution to each, and his or her relationship to any person or cor-
poration having an interest in your organization (such as crea-
tor, donor, director, trustee, officer, etc.).

Group Returns.—A group return on this form may be filed
by a central, parent, or like organization for two or more local
organizations which: (a) are affiliated with the central organi-
zation at the close of the central organization’s annual account-
ing period; (b) are subject to the general supervision or control
of the central organization; (c) are exempt from tax under a
group exemption letter which is currently in effect. However
each local organization included in the group return must meet
the requirements under “Who May File” above.

Each local organization must annually authorize the central
organization in writing to include it in the group return and also
must annually file statements verified under oath or affirmation
with the central organization of the information required by this
short form return. The group return shall be in addition to the
separate return of the central organization but in lieu of sep-
arate returns by the local organizations included in the group
return. There shall be attached to such group return schedules
showing separately (a) the total number, names, addresses and
employer identification numbers of the local organizations
indlude and (b) the same information for those not included

erein.

When and Where to File.—This return must be filed on or
before the 15th day of the fifth month following the close of
the organization's annual accounting period with the Mid-
Atlantic Service Center. Mail the return to the Internal Revenue
Service Center, 11601 Roosevelt Boulevard, Philadelphia, Penn-
sylvania 19155,

‘Yevirded US. GOVERNMENTPRINTING OFFICE 1969—-0-37-033,

The law provides penalties for failure to furnish the informa-
tion required by this form.

Final Return.—If the organization ceases to exist and this is
the last return it is required to file, write “FINAL RETURN” at
the top of the form.

Form 990-T.—An organization described in section 501(c)
(3) [except a church, a convention or association of churches],
including a hospital service organization described in section
501(e), must file a return on Form 990-T on income de-
rived from business which is unrelated to the purpose on which
the organization's exemption is based or from certain rentals
from property leased to others on a long-term basis. Each
business activity not reported on Form 990—T must be sub-
stantially related to the exempt purpose. For more complete
details obtain Form 990-T from your Internal Revenue office.

Information Returns.—Every organization engaged in a trade
or business which includes for this purpose all exempt func-
tions shall make an information return on Forms 1099 and 1096
with respect to payments made during the calendar year in the
course of such trade or business concerning certain dividends,
earnings, interest, rents, royalties, annuities, pensions, foreign
items; and prizes, awards, and commissions to nonemployees.
(See Section 1.6041-1, Income Tax Regulations.) Forms 1099
and 1096 are required to be submitted for payments of divi-
dends or interest aggregating $10 or more. (See Sections
1.6042-2 and 1.6049-1, Income Tax Regulations.)

Label—Name, Address, and Employer Identification Num-
ber.—if you received a Form 990A or 990A(SF) from the Inter-
nal Revenue Service with a preaddressed removable label,
please affix the removable label to the name and address area
of the return you will file. If the name or address on the label
is wrong, draw a single line through the incorrect portion and
enter the correct information.

You should have only one identification number. If you have
more than one number and have not been advised which one
to use, you should notify the Internal Revenue office where you
file your return of the numbers you have, the name and address
to which each number was assigned, and the address of your
principal office. The Service will then advise you which number
to use.

Signature and Verification—The return must be signed
either by the president, vice president, treasurer, assistant
treasurer, chief accounting officer, or other corporate officer
(such as tax officer) who is authorized to sign. A receiver,
trustee, or assignee must sign any return which he is required
to file on behalf of a corporation. If the return is filed on behalf
of a trust, it must be signed by the duly authorized trustee or
trustees. The return must also be signed by any person, firm, or
corporation who prepared the return. If the return is prepared
by a firm or corporation, it should be signed in the name of the
firm or corporation. The verification is not required if the return
is prepared by a regular full-time employee of the organization.

Organizations Organized or Created in a Foreign Country or
United States Possession.—Amounts must be reported in
United States currency (state conversion rate used) and infor-
mation must be furnished in the English language. All items
must be reported in aggregate including amount from both
within and without the United States.

95 -2226867 16—80647-1