Form 990-EZ

Department of the Treasury 

Internal Revenue Service

Short Form 

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) 

▶ Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities,

and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions). 

All other organizations with gross receipts less than $200,000 and total assets less than $500,000 

at the end of the year may use this form. 

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

OMB No. 1545-1150

2012

Open to Public 

Inspection 

A For the 2012 calendar year, or tax year beginning , 2012, and ending , 20 

B Check if applicable: 

Address change

Name change

Initial return

Terminated

Amended return

Application pending

C Name of organization 

Number and street (or P.O. box, if mail is not delivered to street address) Room/suite

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

D Employer identification number 

E Telephone number 

F Group Exemption 

Number ▶

G Accounting Method: Cash Accrual Other (specify) ▶ H Check ▶ if the organization is not 

required to attach Schedule B 

(Form 990, 990-EZ, or 990-PF). 

I Website: ▶

J Tax-exempt status (check only one) — 501(c)(3) 501(c) ( ) ◀ (insert no.) 4947(a)(1) or 527 

K Check ▶ if the organization is not a section 509(a)(3) supporting organization or a section 527 organization and its gross receipts are normally 

not more than $50,000. A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if 

the organization chooses to file a return, be sure to file a complete return. 

L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part II, 

 line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ . . . . . . . . . . ▶ $ 

Part I Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I) 

Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . . . .

Revenue 

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 

5 a 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 (Subtract line 5b from line 5a) . . . . 5c 

6 Gaming and fundraising events 

a Gross income from gaming (attach Schedule G if greater than 

$15,000) . . . . . . . . . . . . . . . . . . . . 6a 

b Gross income from fundraising events (not including $ of contributions

from fundraising events reported on line 1) (attach Schedule G if the

sum of such gross income and contributions exceeds $15,000) . . 6b

c Less: direct expenses from gaming and fundraising events . . . 6c 

d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract 

line 6c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6d

7 a 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 (Subtract line 7b from line 7a) . . . . . . . 7c 

8 Other revenue (describe in Schedule O) . . . . . . . . . . . . . . . . . . . 8 

9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 . . . . . . . . . . . . . ▶ 9 

Expenses 

10 Grants and similar amounts paid (list in Schedule O) . . . . . . . . . . . . . . 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 

15 Printing, publications, postage, and shipping . . . . . . . . . . . . . . . . . 15 

16 Other expenses (describe in Schedule O) . . . . . . . . . . . . . . . . . . 16 

17 Total expenses. Add lines 10 through 16 . . . . . . . . . . . . . . . . . ▶ 17 

Net Assets 

18 Excess or (deficit) for the year (Subtract line 17 from line 9) . . . . . . . . . . . . 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 (explain in Schedule O) . . . . . . . . . 20 

21 Net assets or fund balances at end of year. Combine lines 18 through 20 . . . . . . ▶ 21 

For Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 10642I Form 990-EZ (2012) 
Form 990-EZ (2012) Page 2 

Part II Balance Sheets (see the instructions for Part II)

Check if the organization used Schedule O to respond to any question in this Part II . . . . . . . . . .

(A) Beginning of year (B) End of year 

22 Cash, savings, and investments . . . . . . . . . . . . . . . . . 22 

23 Land and buildings . . . . . . . . . . . . . . . . . . . . . . 23 

24 Other assets (describe in Schedule O) . . . . . . . . . . . . . . . 24 

25 Total assets . . . . . . . . . . . . . . . . . . . . . . . . 25 

26 Total liabilities (describe in Schedule O) . . . . . . . . . . . . . . 26 

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

Part III Statement of Program Service Accomplishments (see the instructions for Part III) 

Check if the organization used Schedule O to respond to any question in this Part III . .

What is the organization’s primary exempt purpose? 

Describe the organization’s program service accomplishments for each of its three largest program services, 

as measured by expenses. In a clear and concise manner, describe the services provided, the number of 

persons benefited, and other relevant information for each program title. 

Expenses 

(Required for section 

501(c)(3) and 501(c)(4) 

organizations and section 

4947(a)(1) trusts; optional 

for others.) 

28 

(Grants $ ) If this amount includes foreign grants, check here . . . . ▶ 28a 

29 

(Grants $ ) If this amount includes foreign grants, check here . . . . ▶ 29a 

30 

(Grants $ ) If this amount includes foreign grants, check here . . . . ▶ 30a 

31 Other program services (describe in Schedule O) . . . . . . . . . . . . . . . . . .

(Grants $ ) If this amount includes foreign grants, check here . . . . ▶ 31a 

32 Total program service expenses (add lines 28a through 31a) . . . . . . . . . . . . . ▶ 32 

Part IV List of Officers, Directors, Trustees, and Key Employees List each one even if not compensated (see the instructions for Part IV) 

Check if the organization used Schedule O to respond to any question in this Part IV . . . . . . . . .

(a) Name and title

(b) Average 

hours per week 

devoted to position 

(c) Reportable 

compensation 

(Forms W-2/1099-MISC) 

(if not paid, enter -0-)

(d) Health benefits, 

contributions to employee 

benefit plans, and 

deferred compensation 

(e) Estimated amount of 

other compensation

Form 990-EZ (2012) 
Form 990-EZ (2012) Page 3 

Part V Other Information (Note the Schedule A and personal benefit contract statement requirements in the 

instructions for Part V) Check if the organization used Schedule O to respond to any question in this Part V .

Yes No 

33 Did the organization engage in any significant activity not previously reported to the IRS? If “Yes,” provide a 

detailed description of each activity in Schedule O . . . . . . . . . . . . . . . . . . . 33 

34 Were any significant changes made to the organizing or governing documents? If “Yes,” attach a conformed 

copy of the amended documents if they reflect a change to the organization's name. Otherwise, explain the

change on Schedule O (see instructions) . . . . . . . . . . . . . . . . . . . . . . 34 

35 a Did the organization have unrelated business gross income of $1,000 or more during the year from business

activities (such as those reported on lines 2, 6a, and 7a, among others)? . . . . . . . . . . . . 35a 

b If “Yes,” to line 35a, has the organization filed a Form 990-T for the year? If “No,” provide an explanation in Schedule O 35b 

c Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, 

reporting, and proxy tax requirements during the year? If “Yes,” complete Schedule C, Part III . . . . . 35c 

36 Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets 

during the year? If “Yes,” complete applicable parts of Schedule N . . . . . . . . . . . . . 36 

37 a 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? . . . . . . . . . . . . . . . . . . 37b 

38a Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were 

any such loans made in a prior year and still outstanding at the end of the tax year covered by this return? . 38a 

b If “Yes,” complete Schedule L, Part II and enter the total amount involved . . . . 38b 

39 Section 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 

40 a Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under: 

section 4911 ▶ ; section 4912 ▶ ; section 4955 ▶

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

transaction during the year, or did it engage in an excess benefit transaction in a prior year that has not been 

reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I . . . . . . . 40b 

c Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on 

organization managers or disqualified persons during the year under sections 4912, 

4955, and 4958 . . . . . . . . . . . . . . . . . . . . . . . ▶

d Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c 

reimbursed by the organization . . . . . . . . . . . . . . . . . ▶

e All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter 

transaction? If “Yes,” complete Form 8886-T . . . . . . . . . . . . . . . . . . . . . 40e 

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

42a The organization's books are in care of ▶ Telephone no. ▶

Located at ▶ ZIP + 4 ▶

b At any time during the calendar year, did the organization have an interest in or a signature or other authority over 

a financial account in a foreign country (such as a bank account, securities account, or other financial account)? 

Yes No 

42b 

If “Yes,” enter the name of the foreign country: ▶

See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank 

and Financial Accounts. 

c At any time during the calendar year, did the organization maintain an office outside the U.S.? . . . . . 42c 

If “Yes,” enter the name of the foreign country: ▶

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

and enter the amount of tax-exempt interest received or accrued during the tax year . . . . . ▶ 43 

Yes No 

44 a Did the organization maintain any donor advised funds during the year? If “Yes,” Form 990 must be

completed instead of Form 990-EZ . . . . . . . . . . . . . . . . . . . . . . . . 44a 

b Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be

completed instead of Form 990-EZ . . . . . . . . . . . . . . . . . . . . . . . . 44b 

c Did the organization receive any payments for indoor tanning services during the year? . . . . . . . 44c 

d If "Yes" to line 44c, has the organization filed a Form 720 to report these payments? If "No," provide an

explanation in Schedule O . . . . . . . . . . . . . . . . . . . . . . . . . . . 44d 

45 a Did the organization have a controlled entity within the meaning of section 512(b)(13)? . . . . . . . 45a 

45 b Did the organization receive any payment from or engage in any transaction with a controlled entity within the

meaning of section 512(b)(13)? If “Yes,” Form 990 and Schedule R may need to be completed instead of

Form 990-EZ (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 45b 

Form 990-EZ (2012) 
Form 990-EZ (2012) Page 4 

Yes No 

46 Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition

to candidates for public office? If “Yes,” complete Schedule C, Part I . . . . . . . . . . . . . 46 

Part VI Section 501(c)(3) organizations only 

All section 501(c)(3) organizations must answer questions 47–49b and 52, and complete the tables for lines 

50 and 51

Check if the organization used Schedule O to respond to any question in this Part VI . . . . . . . . .

Yes No

47 Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax 

year? If “Yes,” complete Schedule C, Part II . . . . . . . . . . . . . . . . . . . . . 47 

48 Is the organization a school as described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E . . . . 48 

49 a Did the organization make any transfers to an exempt non-charitable related organization? . . . . . . 49a 

b If “Yes,” was the related organization a section 527 organization? . . . . . . . . . . . . . . 49b 

50 Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key 

employees) who each received more than $100,000 of compensation from the organization. If there is none, enter “None.” 

(a) Name and title of each employee 

paid more than $100,000 

(b) Average 

hours per week 

devoted to position 

(c) Reportable 

compensation 

(Forms W-2/1099-MISC)

(d) Health benefits, 

contributions to employee 

benefit plans, and deferred 

compensation

(e) Estimated amount of 

other compensation 

f Total number of other employees paid over $100,000 . . . . ▶

51 Complete this table for the organization's five highest compensated independent contractors who each received more than 

$100,000 of compensation from the organization. If there is none, enter “None.” 

(a) Name and address of each independent contractor paid more than $100,000 (b) Type of service (c) Compensation 

d Total number of other independent contractors each receiving over $100,000 . . ▶

52 Did the organization complete Schedule A? Note: All section 501(c)(3) organizations and 4947(a)(1) 

nonexempt charitable trusts must attach a completed Schedule A . . . . . . . . . . . . . ▶ Yes No

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is 

true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge. 

Sign 

Here 

▲

Signature of officer Date 

▲

Type or print name and title

Paid 

Preparer 

Use Only

Print/Type preparer’s name Preparer's signature Date Check if 

self-employed

PTIN

Firm’s name ▶ Firm's EIN ▶

Firm's address ▶ Phone no.

May the IRS discuss this return with the preparer shown above? See instructions . . . . . . . . . . ▶ Yes No

 Form 990-EZ (2012)