LAKELAND, FL Phone no May the IRS discuss this return with the preparer shown above? (see instructions)...

Transcription

1 Form Under setion 0(), 7, or 97()() of the Internl Revenue Code (exept privte foundtions) Deprtment of the Tresury u Do not enter soil seurity numers on this form s it my e mde puli. Internl Revenue Servie u Informtion out Form 990 nd its instrutions is t A For the 0 lendr yer, or tx yer eginning, nd ending B I J K Ativities & Governne Revenue Expenses Net Assets or Fund Blnes Chek if pplile: Address hnge Nme hnge Initil return Finl return/ terminted 990 Amended return Applition pending Tx-exempt sttus: Wesite: u Form of orgniztion: Prt I C Nme of orgniztion F Doing usiness s Return of Orgniztion Exempt From Inome Tx Numer nd street (or P.O. ox if mil is not delivered to street ddress) City or town, stte or provine, ountry, nd ZIP or foreign postl ode Nme nd ddress of prinipl offier: 0() 97()() or 7 Grnts nd similr mounts pid (Prt I, olumn (A), lines ). Benefits pid to or for memers (Prt I, olumn (A), line ) Slries, other ompenstion, employee enefits (Prt I, olumn (A), lines 0)..... Professionl fundrising fees (Prt I, olumn (A), line e) Totl fundrising expenses (Prt I, olumn (D), line ) u 8,98. 7 Other expenses (Prt I, olumn (A), lines d, f e)..... Totl expenses. Add lines 7 (must equl Prt I, olumn (A), line ) Room/suite E Telephone numer G Gross reeipts OMB Open to Puli Inspetion D Employer identifition numer H() Is this group return for suordintes? H() Are ll suordintes inluded? If "," tth list. (see instrutions) H() Group exemption numer u Corportion Trust Assoition Other u L Yer of formtion: 00 M Stte of legl domiile: FL Summry Briefly desrie the orgniztion's mission or most signifint tivities: Chek this ox u if the orgniztion disontinued its opertions or disposed of more thn % of its net ssets. Numer of voting memers of the governing ody (Prt VI, line ) Numer of independent voting memers of the governing ody (Prt VI, line ) Totl numer of individuls employed in lendr yer 0 (Prt V, line ).... Totl numer of volunteers (estimte if neessry)... 7 Totl unrelted usiness revenue from Prt VIII, olumn (C), line..... Net unrelted usiness txle inome from Form 990-T, line.. Prior Yer LAKELAND HILLS BLVD LAKELAND VOLUNTEERS IN MEDICINE INC LAKELAND FL 80 ROBERT YATES 0 LAKELAND HILLS BLVD LAKELAND FL 80 0()() ( ) t (insert no.) TO PROVIDE MEDICAL CARE TO THE NEEDY IN THE LAKELAND AREA. Contriutions nd grnts (Prt VIII, line h).... Progrm servie revenue (Prt VIII, line g)... Investment inome (Prt VIII, olumn (A), lines,, nd 7d) Other revenue (Prt VIII, olumn (A), lines, d, 8, 9, 0, nd e)... Totl revenue dd lines 8 through (must equl Prt VIII, olumn (A), line )..... Revenue less expenses. Sutrt line 8 from line 0 Totl ssets (Prt, line )..... Totl liilities (Prt, line )... Net ssets or fund lnes. Sutrt line from line 0.. Prt II Signture Blok 7 7 Beginning of Current Yer Current Yer End of Yer Under penlties of perjury, I delre tht I hve exmined this return, inluding ompnying shedules nd sttements, nd to the est of my knowledge nd elief, it is true, orret, nd omplete. Delrtion of preprer (other thn offier) is sed on ll informtion of whih preprer hs ny knowledge ,9,0 0 0,090,009,7,7,00,7,, 8,7,0,8,09,9,0 00,9 708, 0 77, 8,8,9,88,0,98 -,9 0,9,87,00,00,7 0,70 9,9,8,0,9,0 Sign Here Pid Preprer Use Only Signture of offier ROBERT YATES Type or print nme nd title Print/Type preprer's nme } For Pperwork Redution At tie, see the seprte instrutions. PRESIDENT/CEO Preprer's signture Dte Chek if PTIN DAVID R. RAMOS, CPA DAVID R. RAMOS, CPA 0/7/7 Firm's nme Firm's EIN } Dte self-employed LAKELAND, FL 8 Phone no Firm's ddress } My the IRS disuss this return with the preprer shown ove? (see instrutions)... P0077 DAVID R. RAMOS, CPA OLD ROAD 7 Form 990 (0)

2 Form 990 (0) Pge Prt III Sttement of Progrm Servie Aomplishments Briefly desrie the orgniztion's mission: Did the orgniztion undertke ny signifint progrm servies during the yer whih were not listed on the prior Form 990 or 990-EZ?..... If "," desrie these new servies on Shedule O. Did the orgniztion ese onduting, or mke signifint hnges in how it onduts, ny progrm servies?.. If "," desrie these hnges on Shedule O. Desrie the orgniztion's progrm servie omplishments for eh of its three lrgest progrm servies, s mesured y expenses. Setion 0()() nd 0()() orgniztions re required to report the mount of grnts nd llotions to others, the totl expenses, nd revenue, if ny, for eh progrm servie reported. (Code:.. ) (Expenses inluding grnts of..... ) (Revenue..... ) )..... (Revenue )..... inluding grnts of ) (Expenses (Code: (Code: inluding grnts of..... ) ) (Expenses..... ) (Revenue. d Other progrm servies (Desrie in Shedule O.) (Revenue ) (Expenses ) inluding grnts of e Totl progrm servie expenses u Form 990 (0) Chek if Shedule O ontins response or note to ny line in this Prt III TO PROVIDE MEDICAL CARE TO THE NEEDY IN THE LAKELAND AREA.,,,7 TO PROVIDE MEDICAL CARE TO THE NEEDY IN THE LAKELAND AREA.,, 09

3 Form 990 (0) Prt IV Cheklist of Required Shedules d e f Is the orgniztion desried in setion 0()() or 97()() (other thn privte foundtion)? If, omplete Shedule A.... Is the orgniztion required to omplete Shedule B, Shedule of Contriutors (see instrutions)?. Did the orgniztion engge in diret or indiret politil mpign tivities on ehlf of or in opposition to ndidtes for puli offie? If, omplete Shedule C, Prt I Setion 0()() orgniztions. Did the orgniztion engge in loying tivities, or hve setion 0(h) eletion in effet during the tx yer? If "," omplete Shedule C, Prt II... Is the orgniztion setion 0()(), 0()(), or 0()() orgniztion tht reeives memership dues, ssessments, or similr mounts s defined in Revenue Proedure 98-9? If "," omplete Shedule C, Prt III..... Did the orgniztion mintin ny donor dvised funds or ny similr funds or ounts for whih donors hve the right to provide dvie on the distriution or investment of mounts in suh funds or ounts? If, omplete Shedule D, Prt I.... Did the orgniztion reeive or hold onservtion esement, inluding esements to preserve open spe, the environment, histori lnd res, or histori strutures? If, omplete Shedule D, Prt II. Did the orgniztion mintin olletions of works of rt, historil tresures, or other similr ssets? If, omplete Shedule D, Prt III.. Did the orgniztion report n mount in Prt, line, for esrow or ustodil ount liility, serve s ustodin for mounts not listed in Prt ; or provide redit ounseling, det mngement, redit repir, or det negotition servies? If, omplete Shedule D, Prt IV Did the orgniztion, diretly or through relted orgniztion, hold ssets in temporrily restrited endowments, permnent endowments, or qusi-endowments? If, omplete Shedule D, Prt V.... If the orgniztion's nswer to ny of the following questions is, then omplete Shedule D, Prts VI, VII, VIII, I, or s pplile. Did the orgniztion report n mount for lnd, uildings, nd equipment in Prt, line 0? If "," omplete Shedule D, Prt VI.. Did the orgniztion report n mount for investments other seurities in Prt, line tht is % or more of its totl ssets reported in Prt, line? If "," omplete Shedule D, Prt VII. Did the orgniztion report n mount for investments progrm relted in Prt, line tht is % or more of its totl ssets reported in Prt, line? If "," omplete Shedule D, Prt VIII Did the orgniztion report n mount for other ssets in Prt, line tht is % or more of its totl ssets reported in Prt, line? If "," omplete Shedule D, Prt I Did the orgniztion report n mount for other liilities in Prt, line? If "," omplete Shedule D, Prt..... Did the orgniztion's seprte or onsolidted finnil sttements for the tx yer inlude footnote tht ddresses the orgniztion's liility for unertin tx positions under FIN 8 (ASC 70)? If "," omplete Shedule D, Prt.. Did the orgniztion otin seprte, independent udited finnil sttements for the tx yer? If, omplete Shedule D, Prts I nd II... Ws the orgniztion inluded in onsolidted, independent udited finnil sttements for the tx yer? If "," nd if the orgniztion nswered "" to line, then ompleting Shedule D, Prts I nd II is optionl..... Is the orgniztion shool desried in setion 70()()(A)(ii)? If, omplete Shedule E... Did the orgniztion mintin n offie, employees, or gents outside of the United Sttes? Did the orgniztion hve ggregte revenues or expenses of more thn 0,000 from grntmking, fundrising, usiness, investment, nd progrm servie tivities outside the United Sttes, or ggregte foreign investments vlued t 00,000 or more? If, omplete Shedule F, Prts I nd IV... Did the orgniztion report on Prt I, olumn (A), line, more thn,000 of grnts or other ssistne to or for ny foreign orgniztion? If, omplete Shedule F, Prts II nd IV.... Did the orgniztion report on Prt I, olumn (A), line, more thn,000 of ggregte grnts or other ssistne to or for foreign individuls? If, omplete Shedule F, Prts III nd IV Did the orgniztion report totl of more thn,000 of expenses for professionl fundrising servies on Prt I, olumn (A), lines nd e? If, omplete Shedule G, Prt I (see instrutions) Did the orgniztion report more thn,000 totl of fundrising event gross inome nd ontriutions on Prt VIII, lines nd 8? If "," omplete Shedule G, Prt II. Did the orgniztion report more thn,000 of gross inome from gming tivities on Prt VIII, line 9? If "," omplete Shedule G, Prt III d e f Pge Form 990 (0)

4 Form 990 (0) Pge Prt IV Cheklist of Required Shedules (ontinued) d Did the orgniztion operte one or more hospitl filities? If, omplete Shedule H. If to line 0, did the orgniztion tth opy of its udited finnil sttements to this return?.. Did the orgniztion report more thn,000 of grnts or other ssistne to ny domesti orgniztion or domesti government on Prt I, olumn (A), line? If, omplete Shedule I, Prts I nd II.. Did the orgniztion report more thn,000 of grnts or other ssistne to or for domesti individuls on Prt I, olumn (A), line? If, omplete Shedule I, Prts I nd III Did the orgniztion nswer to Prt VII, Setion A, line,, or out ompenstion of the orgniztion's urrent nd former offiers, diretors, trustees, key employees, nd highest ompensted employees? If "," omplete Shedule J... Did the orgniztion hve tx-exempt ond issue with n outstnding prinipl mount of more thn 00,000 s of the lst dy of the yer, tht ws issued fter Deemer, 00? If, nswer lines through d nd omplete Shedule K. If, go to line.... Did the orgniztion invest ny proeeds of tx-exempt onds eyond temporry period exeption?.... Did the orgniztion mintin n esrow ount other thn refunding esrow t ny time during the yer to defese ny tx-exempt onds?.... Did the orgniztion t s n on ehlf of issuer for onds outstnding t ny time during the yer?... Setion 0()(), 0()(), nd 0()(9) orgniztions. Did the orgniztion engge in n exess enefit trnstion with disqulified person during the yer? If, omplete Shedule L, Prt I Is the orgniztion wre tht it engged in n exess enefit trnstion with disqulified person in prior yer, nd tht the trnstion hs not een reported on ny of the orgniztion's prior Forms 990 or 990-EZ? If "," omplete Shedule L, Prt I.. Did the orgniztion report ny mount on Prt, line,, or for reeivles from or pyles to ny urrent or former offiers, diretors, trustees, key employees, highest ompensted employees, or disqulified persons? If "," omplete Shedule L, Prt II Did the orgniztion provide grnt or other ssistne to n offier, diretor, trustee, key employee, sustntil ontriutor or employee thereof, grnt seletion ommittee memer, or to % ontrolled entity or fmily memer of ny of these persons? If, omplete Shedule L, Prt III.... Ws the orgniztion prty to usiness trnstion with one of the following prties (see Shedule L, Prt IV instrutions for pplile filing thresholds, onditions, nd exeptions): A urrent or former offier, diretor, trustee, or key employee? If "," omplete Shedule L, Prt IV.... A fmily memer of urrent or former offier, diretor, trustee, or key employee? If "," omplete Shedule L, Prt IV An entity of whih urrent or former offier, diretor, trustee, or key employee (or fmily memer thereof) ws n offier, diretor, trustee, or diret or indiret owner? If, omplete Shedule L, Prt IV Did the orgniztion reeive more thn,000 in non-sh ontriutions? If, omplete Shedule M Did the orgniztion reeive ontriutions of rt, historil tresures, or other similr ssets, or qulified onservtion ontriutions? If, omplete Shedule M Did the orgniztion liquidte, terminte, or dissolve nd ese opertions? If, omplete Shedule N, Prt I Did the orgniztion sell, exhnge, dispose of, or trnsfer more thn % of its net ssets? If "," omplete Shedule N, Prt II... Did the orgniztion own 00% of n entity disregrded s seprte from the orgniztion under Regultions setions nd ? If, omplete Shedule R, Prt I... Ws the orgniztion relted to ny tx-exempt or txle entity? If, omplete Shedule R, Prts II, III, or IV, nd Prt V, line.. Did the orgniztion hve ontrolled entity within the mening of setion ()()?..... If "" to line, did the orgniztion reeive ny pyment from or engge in ny trnstion with ontrolled entity within the mening of setion ()()? If, omplete Shedule R, Prt V, line. Setion 0()() orgniztions. Did the orgniztion mke ny trnsfers to n exempt non-hritle relted orgniztion? If, omplete Shedule R, Prt V, line Did the orgniztion ondut more thn % of its tivities through n entity tht is not relted orgniztion nd tht is treted s prtnership for federl inome tx purposes? If, omplete Shedule R, Prt VI Did the orgniztion omplete Shedule O nd provide explntions in Shedule O for Prt VI, lines nd 9? te. All Form 990 filers re required to omplete Shedule O. 0 0 d Form 990 (0)

5 Form 990 (0) Pge Prt V Sttements Regrding Other IRS Filings nd Tx Compline Chek if Shedule O ontins response or note to ny line in this Prt V d e f g h Enter the numer reported in Box of Form 09. Enter -0- if not pplile... Enter the numer of Forms W-G inluded in line. Enter -0- if not pplile Did the orgniztion omply with kup withholding rules for reportle pyments to vendors nd reportle gming (gmling) winnings to prize winners?. Enter the numer of employees reported on Form W-, Trnsmittl of Wge nd Tx Sttements, filed for the lendr yer ending with or within the yer overed y this return.. If t lest one is reported on line, did the orgniztion file ll required federl employment tx returns? te. If the sum of lines nd is greter thn 0, you my e required to e-file (see instrutions) Did the orgniztion hve unrelted usiness gross inome of,000 or more during the yer?... If, hs it filed Form 990-T for this yer? If to line, provide n explntion in Shedule O.. At ny time during the lendr yer, did the orgniztion hve n interest in, or signture or other uthority over, finnil ount in foreign ountry (suh s nk ount, seurities ount, or other finnil ount)?.. If, enter the nme of the foreign ountry: u See instrutions for filing requirements for FinCEN Form, Report of Foreign Bnk nd Finnil Aounts Ws the orgniztion prty to prohiited tx shelter trnstion t ny time during the tx yer? Did ny txle prty notify the orgniztion tht it ws or is prty to prohiited tx shelter trnstion?..... If to line or, did the orgniztion file Form 888-T?.. Does the orgniztion hve nnul gross reeipts tht re normlly greter thn 00,000, nd did the orgniztion soliit ny ontriutions tht were not tx dedutile s hritle ontriutions?..... If, did the orgniztion inlude with every soliittion n express sttement tht suh ontriutions or gifts were not tx dedutile?.. Orgniztions tht my reeive dedutile ontriutions under setion 70(). Did the orgniztion reeive pyment in exess of 7 mde prtly s ontriution nd prtly for goods If, did the orgniztion notify the donor of the vlue of the goods or servies provided? Did the orgniztion sell, exhnge, or otherwise dispose of tngile personl property for whih it ws required to file Form 88?..... If, indite the numer of Forms 88 filed during the yer. 7d Did the orgniztion reeive ny funds, diretly or indiretly, to py premiums on personl enefit ontrt?.. Did the orgniztion, during the yer, py premiums, diretly or indiretly, on personl enefit ontrt? If the orgniztion reeived ontriution of qulified intelletul property, did the orgniztion file Form 8899 s required?.. If the orgniztion reeived ontriution of rs, ots, irplnes, or other vehiles, did the orgniztion file Form 098-C? Sponsoring orgniztions mintining donor dvised funds. Did donor dvised fund mintined y the sponsoring orgniztion hve exess usiness holdings t ny time during the yer? Sponsoring orgniztions mintining donor dvised funds. Did the sponsoring orgniztion mke ny txle distriutions under setion 9?. Did the sponsoring orgniztion mke distriution to donor, donor dvisor, or relted person?. Setion 0()(7) orgniztions. Enter: Initition fees nd pitl ontriutions inluded on Prt VIII, line..... Gross reeipts, inluded on Form 990, Prt VIII, line, for puli use of lu filities Setion 0()() orgniztions. Enter: Gross inome from memers or shreholders Gross inome from other soures (Do not net mounts due or pid to other soures ginst mounts due or reeived from them.). Setion 97()() non-exempt hritle trusts. Is the orgniztion filing Form 990 in lieu of Form 0?... If, enter the mount of tx-exempt interest reeived or rued during the yer. Setion 0()(9) qulified nonprofit helth insurne issuers. (FBAR). nd servies provided to the pyor?.. Is the orgniztion liensed to issue qulified helth plns in more thn one stte?.. te. See the instrutions for dditionl informtion the orgniztion must report on Shedule O. Enter the mount of reserves the orgniztion is required to mintin y the sttes in whih the orgniztion is liensed to issue qulified helth plns. Enter the mount of reserves on hnd. Did the orgniztion reeive ny pyments for indoor tnning servies during the tx yer?. If "," hs it filed Form 70 to report these pyments? If "," provide n explntion in Shedule O Form 990 (0) e 7f 7g 7h 8 9 9

6 Form 990 (0) Pge Prt VI Governne, Mngement, nd Dislosure For eh "" response to lines through 7 elow, nd for "" response to line 8, 8, or 0 elow, desrie the irumstnes, proesses, or hnges in Shedule O. See instrutions. Chek if Shedule O ontins response or note to ny line in this Prt VI..... Setion A. Governing Body nd Mngement orgniztion s exempt sttus with respet to suh rrngements? Setion C. Dislosure 7 List the sttes with whih opy of this Form 990 is required to e filed u... NONE. 8 Setion 0 requires n orgniztion to mke its Forms 0 (or 0 if pplile), 990, nd 990-T (Setion 0()()s only) Enter the numer of voting memers of the governing ody t the end of the tx yer If there re mteril differenes in voting rights mong memers of the governing ody, or Enter the numer of voting memers inluded in line, ove, who re independent Did ny offier, diretor, trustee, or key employee hve fmily reltionship or usiness reltionship with ny other offier, diretor, trustee, or key employee? Did the orgniztion delegte ontrol over mngement duties ustomrily performed y or under the diret supervision of offiers, diretors, or trustees, or key employees to mngement ompny or other person?... Did the orgniztion mke ny signifint hnges to its governing douments sine the prior Form 990 ws filed?.... Did the orgniztion eome wre during the yer of signifint diversion of the orgniztion s ssets? Did the orgniztion hve memers or stokholders?..... Did the orgniztion hve memers, stokholders, or other persons who hd the power to elet or ppoint one or more memers of the governing ody? Are ny governne deisions of the orgniztion reserved to (or sujet to pprovl y) memers, stokholders, or persons other thn the governing ody?.. Did the orgniztion ontemporneously doument the meetings held or written tions undertken during the yer y the following: The governing ody?.... Eh ommittee with uthority to t on ehlf of the governing ody?. Is there ny offier, diretor, trustee, or key employee listed in Prt VII, Setion A, who nnot e rehed t the orgniztion s miling ddress? If, provide the nmes nd ddresses in Shedule O Setion B. Poliies (This Setion B requests informtion out poliies not required y the Internl Revenue Code.) Did the orgniztion hve lol hpters, rnhes, or ffilites? If, did the orgniztion hve written poliies nd proedures governing the tivities of suh hpters, ffilites, nd rnhes to ensure their opertions re onsistent with the orgniztion's exempt purposes?..... Hs the orgniztion provided omplete opy of this Form 990 to ll memers of its governing ody efore filing the form? Desrie in Shedule O the proess, if ny, used y the orgniztion to review this Form if the governing ody delegted rod uthority to n exeutive ommittee or similr ommittee, explin in Shedule O. Did the orgniztion hve written onflit of interest poliy? If, go to line... Were offiers, diretors, or trustees, nd key employees required to dislose nnully interests tht ould give rise to onflits?.... Did the orgniztion regulrly nd onsistently monitor nd enfore ompline with the poliy? If, desrie in Shedule O how this ws done.. Did the orgniztion hve written whistlelower poliy?.. Did the orgniztion hve written doument retention nd destrution poliy? Did the proess for determining ompenstion of the following persons inlude review nd pprovl y independent persons, omprility dt, nd ontemporneous sustntition of the deliertion nd deision? The orgniztion s CEO, Exeutive Diretor, or top mngement offiil Other offiers or key employees of the orgniztion If to line or, desrie the proess in Shedule O (see instrutions). Did the orgniztion invest in, ontriute ssets to, or prtiipte in joint venture or similr rrngement with txle entity during the yer?.. If, did the orgniztion follow written poliy or proedure requiring the orgniztion to evlute its prtiiption in joint venture rrngements under pplile federl tx lw, nd tke steps to sfegurd the ville for puli inspetion. Indite how you mde these ville. Chek ll tht pply. Own wesite Another's wesite Upon request Desrie in Shedule O whether (nd if so, how) the orgniztion mde its governing douments, onflit of interest poliy, nd finnil sttements ville to the puli during the tx yer. Stte the nme, ddress, nd telephone numer of the person who possesses the orgniztion's ooks nd reords: u ROBERT YATES Other (explin in Shedule O) 0 LAKELAND HILLS BLVD LAKELAND FL Form 990 (0)

7 Form 990 (0) Pge 7 Prt VII Compenstion of Offiers, Diretors, Trustees, Key Employees, Highest Compensted Employees, nd Independent Contrtors Chek if Shedule O ontins response or note to ny line in this Prt VII... Setion A. Offiers, Diretors, Trustees, Key Employees, nd Highest Compensted Employees Complete this tle for ll persons required to e listed. Report ompenstion for the lendr yer ending with or within the orgniztion's tx yer. List ll of the orgniztion's urrent offiers, diretors, trustees (whether individuls or orgniztions), regrdless of mount of ompenstion. Enter -0- in olumns (D), (E), nd (F) if no ompenstion ws pid. List ll of the orgniztion's urrent key employees, if ny. See instrutions for definition of "key employee." List the orgniztion's five urrent highest ompensted employees (other thn n offier, diretor, trustee, or key employee) who reeived reportle ompenstion (Box of Form W- nd/or Box 7 of Form 099-MISC) of more thn 00,000 from the orgniztion nd ny relted orgniztions. List ll of the orgniztion's former offiers, key employees, nd highest ompensted employees who reeived more thn 00,000 of reportle ompenstion from the orgniztion nd ny relted orgniztions. List ll of the orgniztion s former diretors or trustees tht reeived, in the pity s former diretor or trustee of the orgniztion, more thn 0,000 of reportle ompenstion from the orgniztion nd ny relted orgniztions. List persons in the following order: individul trustees or diretors; institutionl trustees; offiers; key employees; highest ompensted employees; nd former suh persons. () () () () () () (7) (8) (9) (0) () Chek this ox if neither the orgniztion nor ny relted orgniztion ompensted ny urrent offier, diretor, or trustee. (A) (B) (C) (D) (E) (F) Nme nd Title JONN HOPPE Averge hours per week (list ny hours for relted orgniztions elow dotted line) CHAIRMAN BRUCE BULMAN DIRECTOR KIMBERLY ELMHORST DIRECTOR BEN FAIRCHILD DIRECTOR DENI BURNETTI DIRECTOR JAMES COSSIN DIRECTOR BRUCE ABELS DIRECTOR SHERRIE LONG DIRECTOR BRAD LUNZ DIRECTOR CARLA MORGAN DIRECTOR STEVEN L PETERSON DIRECTOR Position (do not hek more thn one ox, unless person is oth n offier nd diretor/trustee) Individul trustee or diretor Institutionl trustee Offier Key employee Highest ompensted employee Former Reportle ompenstion from the orgniztion (W-/099-MISC) Reportle ompenstion from relted orgniztions (W-/099-MISC) Estimted mount of other ompenstion from the orgniztion nd relted orgniztions Form 990 (0)

8 Form 990 (0) Pge 8 Prt VII Setion A. Offiers, Diretors, Trustees, Key Employees, nd Highest Compensted Employees (ontinued) Su-totl... u Totl from ontinution sheets to Prt VII, Setion A... u 89,89 d Totl (dd lines nd ).... u 89,89 Totl numer of individuls (inluding ut not limited to those listed ove) who reeived more thn 00,000 of reportle ompenstion from the orgniztion u (A) Nme nd title Did the orgniztion list ny former offier, diretor, or trustee, key employee, or highest ompensted employee on line? If, omplete Shedule J for suh individul. For ny individul listed on line, is the sum of reportle ompenstion nd other ompenstion from the orgniztion nd relted orgniztions greter thn 0,000? If, omplete Shedule J for suh individul.. Did ny person listed on line reeive or rue ompenstion from ny unrelted orgniztion or individul for servies rendered to the orgniztion? If, omplete Shedule J for suh person... Setion B. Independent Contrtors (B) Averge hours per week (list ny hours for relted orgniztions elow dotted line) Individul trustee or diretor Institutionl trustee Offier (C) Position (do not hek more thn one ox, unless person is oth n offier nd diretor/trustee) Key employee Complete this tle for your five highest ompensted independent ontrtors tht reeived more thn 00,000 of ompenstion from the orgniztion. Report ompenstion for the lendr yer ending with or within the orgniztion's tx yer. (A) (B) Nme nd usiness ddress Desription of servies Highest ompensted employee Former (D) Reportle ompenstion from the orgniztion (W-/099-MISC) (E) Reportle ompenstion from relted orgniztions (W-/099-MISC) Estimted mount of other ompenstion from the orgniztion nd relted orgniztions () REV. RICHARD RICHARDSON DIRECTOR 0.00 () DAVID ROBINSON DIRECTOR () WEYMON SNUGGS.00 CHAIRMAN () DOUG THOMAS.00 DIRECTOR () DR. DOUG EBERSOLE.00 DIRECTOR (7) KEVIN MCWILLIAMS.00 DIRECTOR (8) DR. JOHN PAUL.00 DIRECTOR (9) JAMES SIDOU.00 DIRECTOR (F) (C) Compenstion Totl numer of independent ontrtors (inluding ut not limited to those listed ove) who reeived more thn 00,000 of ompenstion from the orgniztion u 0 Form 990 (0)

9 Form 990 (0) Pge 9 Prt VIII Sttement of Revenue Chek if Shedule O ontins response or note to ny line in this Prt VIII.. Contriutions, Gifts, Grnts nd Other Similr Amounts Progrm Servie Revenue Other Revenue d e f g h d e f g Federted mpigns Memership dues... Fundrising events.. Relted orgniztions Government grnts (ontriutions)... All other ontriutions, gifts, grnts, nd similr mounts not inluded ove nsh ontriutions inluded in lines -f: Totl. Add lines f.... d e All other progrm servie revenue... f Totl. Add lines f.... Investment inome (inluding dividends, interest, nd other similr mounts) u Inome from investment of tx-exempt ond proeedsu Roylties... u Gross rents Less: rentl exps. Rentl in. or (loss) (i) Rel (ii) l d Net rentl inome or (loss) Gross mount from (i) Seurities (ii) Other sles of ssets other thn inventory Less: ost or other 0 d e sis & sles exps. Gross sles of inventory, less u Busn. Code Gin or (loss) d Net gin or (loss).. u 8 Gross inome from fundrising events (not inluding of ontriutions reported on line ). See Prt IV, line 8. Less: diret expenses... Net inome or (loss) from fundrising events. u 9 Gross inome from gming tivities. See Prt IV, line 9. Less: diret expenses... Net inome or (loss) from gming tivities... u returns nd llownes.. Less: ost of goods sold Net inome or (loss) from sles of inventory.. Misellneous Revenue All other revenue,0 7, Totl. Add lines d Totl revenue. See instrutions u u u Busn. Code u u (A) (B) (C) (D) Totl revenue Relted or Unrelted Revenue exempt funtion revenue usiness revenue exluded from tx under setions -,7,7 RENTAL INCOME,7,7,0,7,,,0 EVENT INCOME,9,0 88, Form 990 (0)

10 Form 990 (0) Pge 0 Prt I Sttement of Funtionl Expenses Setion 0()() nd 0()() orgniztions must omplete ll olumns. All other orgniztions must omplete olumn (A). Chek if Shedule O ontins response or note to ny line in this Prt I. Do not inlude mounts reported on lines, 7, 8, 9, nd 0 of Prt VIII. Grnts nd other ssistne to domesti orgniztions (A) (B) (C) (D) Totl expenses Progrm servie Mngement nd Fundrising expenses generl expenses expenses nd domesti governments. See Prt IV, line.... Grnts nd other ssistne to domesti d e f g d e individuls. See Prt IV, line Grnts nd other ssistne to foreign orgniztions, foreign governments, nd foreign individuls. See Prt IV, lines nd... Benefits pid to or for memers Compenstion of urrent offiers, diretors, trustees, nd key employees.. Compenstion not inluded ove, to disqulified persons (s defined under setion 98(f)()) nd persons desried in setion 98()()(B). Other slries nd wges..... Pension pln ruls nd ontriutions (inlude setion 0(k) nd 0() employer ontriutions) Other employee enefits Pyroll txes..... Fees for servies (non-employees): Mngement.... Legl Aounting Loying.. Professionl fundrising servies. See Prt IV, line 7 Investment mngement fees. Other. (If line g mount exeeds 0% of line, olumn (A) mount, list line g expenses on Shedule O.). Advertising nd promotion..... Offie expenses. Informtion tehnology. Roylties.. Oupny Trvel..... Pyments of trvel or entertinment expenses for ny federl, stte, or lol puli offiils Conferenes, onventions, nd meetings... Interest... Pyments to ffilites... Depreition, depletion, nd mortiztion... Insurne. Other expenses. Itemize expenses not overed ove (List misellneous expenses in line e. If line e mount exeeds 0% of line, olumn (A) mount, list line e expenses on Shedule O.) All other expenses Totl funtionl expenses. Add lines through e..... Joint osts. Complete this line only if the orgniztion reported in olumn (B) joint osts from omined edutionl mpign nd fundrising soliittion. Chek here u if following SOP 98- (ASC 98-70). 89,89,7,98,7,98 0, 78 0,90, 7,78, 9,97 7,,90,97,77,9,9,807,09 9,0 98 7,0, , 7,87,070,777 0,787 7,877,0 8,700, 9,8 8,0 9,9 REPAIRS & MAINTENANCE 9,7 7,97,87, DRUGS & MEDICATIONS 8, 8, OUTSIDE LAB FEES,8,8 UTILITIES 0,0,79 7, ,7 8,,8 0,99,0,98,, 0,7 8,98 Form 990 (0)

11 Form 990 (0) Pge Prt Blne Sheet Chek if Shedule O ontins response or note to ny line in this Prt.. (A) (B) Beginning of yer End of yer Csh non-interest ering , 8, Svings nd temporry sh investments..... Pledges nd grnts reeivle, net ,9,9 Aounts reeivle, net.. Lons nd other reeivles from urrent nd former offiers, diretors, Assets Liilities Net Assets or Fund Blnes other sis. Complete Prt VI of Shedule D... 0 Less: umulted depreition.. 0,0,09,89,0 0,9,7 Investments pulily trded seurities. Investments other seurities. See Prt IV, line.. Investments progrm-relted. See Prt IV, line.. Intngile ssets... Other ssets. See Prt IV, line......,,97,77,08 Totl ssets. Add lines through (must equl line )..,87,00,00,7 7 Aounts pyle nd rued expenses......,70 7,8 8 Grnts pyle Deferred revenue... 9,000 9,7 0 Tx-exempt ond liilities Esrow or ustodil ount liility. Complete Prt IV of Shedule D.... Lons nd other pyles to urrent nd former offiers, diretors, trustees, key employees, nd highest ompensted employees. Complete Prt II of Shedule L.. Lons nd other reeivles from other disqulified persons (s defined under setion 98(f)()), persons desried in setion 98()()(B), nd ontriuting employers nd sponsoring orgniztions of setion 0()(9) voluntry employees' enefiiry orgniztions (see instrutions). Complete Prt II of Shedule L... tes nd lons reeivle, net.. Inventories for sle or use. Prepid expenses nd deferred hrges Lnd, uildings, nd equipment: ost or trustees, key employees, highest ompensted employees, nd disqulified persons. Complete Prt II of Shedule L. Seured mortgges nd notes pyle to unrelted third prties... Unseured notes nd lons pyle to unrelted third prties Other liilities (inluding federl inome tx, pyles to relted third prties, nd other liilities not inluded on lines 7-). Complete Prt of Shedule D Totl liilities. Add lines 7 through Orgniztions tht follow SFAS 7 (ASC 98), hek here u nd omplete lines 7 through 9, nd lines nd. Unrestrited net ssets.... Temporrily restrited net ssets Permnently restrited net ssets Orgniztions tht do not follow SFAS 7 (ASC 98), hek here u nd omplete lines 0 through. Cpitl stok or trust prinipl, or urrent funds Pid-in or pitl surplus, or lnd, uilding, or equipment fund..... Retined ernings, endowment, umulted inome, or other funds..... Totl net ssets or fund lnes Totl liilities nd net ssets/fund lnes..,8, 7,89 8, 9 0,70 9,9,8,0 7,9, ,8,0,9,0,87,00,00,7 Form 990 (0)

12 Form 990 (0) Pge Prt I Reonilition of Net Assets Chek if Shedule O ontins response or note to ny line in this Prt I..... Totl revenue (must equl Prt VIII, olumn (A), line ). Totl expenses (must equl Prt I, olumn (A), line ). Revenue less expenses. Sutrt line from line Net ssets or fund lnes t eginning of yer (must equl Prt, line, olumn (A)). Net unrelized gins (losses) on investments Donted servies nd use of filities 7 Investment expenses Prior period djustments Other hnges in net ssets or fund lnes (explin in Shedule O). 9 0 Net ssets or fund lnes t end of yer. Comine lines through 9 (must equl Prt, line, olumn (B)).. 0 Prt II Finnil Sttements nd Reporting Chek if Shedule O ontins response or note to ny line in this Prt II.... Aounting method used to prepre the Form 990: Csh Arul Were the orgniztion's finnil sttements ompiled or reviewed y n independent ountnt? If "," hek ox elow to indite whether the finnil sttements for the yer were ompiled or Were the orgniztion's finnil sttements udited y n independent ountnt? If "," hek ox elow to indite whether the finnil sttements for the yer were udited on of the udit, review, or ompiltion of its finnil sttements nd seletion of n independent ountnt?.... If the orgniztion hnged either its oversight proess or seletion proess during the tx yer, explin in the Single Audit At nd OMB Cirulr A-?..... If, did the orgniztion undergo the required udit or udits? If the orgniztion did not undergo the Other If the orgniztion hnged its method of ounting from prior yer or heked Other, explin in Shedule O. reviewed on seprte sis, onsolidted sis, or oth: Seprte sis Consolidted sis Both onsolidted nd seprte sis Seprte sis If to line or, does the orgniztion hve ommittee tht ssumes responsiility for oversight Shedule O. seprte sis, onsolidted sis, or oth: Consolidted sis As result of federl wrd, ws the orgniztion required to undergo n udit or udits s set forth in required udit or udits, explin why in Shedule O nd desrie ny steps tken to undergo suh udits Both onsolidted nd seprte sis,9,0,0,98 0,9,8,0 0,0,9,0 Form 990 (0)

13 Form 990 (0) Pge 8 Prt VII Setion A. Offiers, Diretors, Trustees, Key Employees, nd Highest Compensted Employees (ontinued) (A) Nme nd title (B) Averge hours per week (list ny hours for relted orgniztions elow dotted line) Individul trustee or diretor Institutionl trustee Offier (C) Position (do not hek more thn one ox, unless person is oth n offier nd diretor/trustee) Key employee Highest ompensted employee Former (D) Reportle ompenstion from the orgniztion (W-/099-MISC) (E) Reportle ompenstion from relted orgniztions (W-/099-MISC) (F) Estimted mount of other ompenstion from the orgniztion nd relted orgniztions (0) SUSAN LEFRANCOIS DIRECTOR () ROBERT YATES PRESIDENT/CEO , Su-totl... u Totl from ontinution sheets to Prt VII, Setion A... u d Totl (dd lines nd ).... u Totl numer of individuls (inluding ut not limited to those listed ove) who reeived more thn 00,000 of reportle ompenstion from the orgniztion u Did the orgniztion list ny former offier, diretor, or trustee, key employee, or highest ompensted employee on line? If, omplete Shedule J for suh individul. For ny individul listed on line, is the sum of reportle ompenstion nd other ompenstion from the orgniztion nd relted orgniztions greter thn 0,000? If, omplete Shedule J for suh individul.. Did ny person listed on line reeive or rue ompenstion from ny unrelted orgniztion or individul for servies rendered to the orgniztion? If, omplete Shedule J for suh person... Setion B. Independent Contrtors 89,89 Complete this tle for your five highest ompensted independent ontrtors tht reeived more thn 00,000 of ompenstion from the orgniztion. Report ompenstion for the lendr yer ending with or within the orgniztion's tx yer. (A) (B) Nme nd usiness ddress Desription of servies (C) Compenstion Totl numer of independent ontrtors (inluding ut not limited to those listed ove) who reeived more thn 00,000 of ompenstion from the orgniztion u Form 990 (0)

14 SCHEDULE A (Form 990 or 990-EZ) Deprtment of the Tresury Internl Revenue Servie Nme of the orgniztion Prt I (i) Nme of supported orgniztion Puli Chrity Sttus nd Puli Support Complete if the orgniztion is setion 0()() orgniztion or setion 97()() nonexempt hritle trust. u Atth to Form 990 or Form 990-EZ. Employer identifition numer Reson for Puli Chrity Sttus (All orgniztions must omplete this prt.) See instrutions. The orgniztion is not privte foundtion euse it is: (For lines through, hek only one ox.) 7 8 A hurh, onvention of hurhes, or ssoition of hurhes desried in setion 70()()(A)(i). A shool desried in setion 70()()(A)(ii). (Atth Shedule E (Form 990 or 990-EZ).) A hospitl or oopertive hospitl servie orgniztion desried in setion 70()()(A)(iii). OMB A medil reserh orgniztion operted in onjuntion with hospitl desried in setion 70()()(A)(iii). Enter the hospitl's nme, 0 Open to Puli Inspetion ity, nd stte: An orgniztion operted for the enefit of ollege or university owned or operted y governmentl unit desried in setion 70()()(A)(iv). (Complete Prt II.) A federl, stte, or lol government or governmentl unit desried in setion 70()()(A)(v). An orgniztion tht normlly reeives sustntil prt of its support from governmentl unit or from the generl puli desried in setion 70()()(A)(vi). (Complete Prt II.) A ommunity trust desried in setion 70()()(A)(vi). (Complete Prt II.) 9 An griulturl reserh orgniztion desried in setion 70()()(A)(ix) operted in onjuntion with lnd-grnt ollege or university or non-lnd grnt ollege of griulture (see instrutions). Enter the nme, ity, nd stte of the ollege or university: An orgniztion tht normlly reeives: () more thn /% of its support from ontriutions, memership fees, nd gross reeipts from tivities relted to its exempt funtions sujet to ertin exeptions, nd () no more thn /% of its support from gross investment inome nd unrelted usiness txle inome (less setion tx) from usinesses quired y the orgniztion fter June 0, 97. See setion 09()(). (Complete Prt III.) (A) d u Informtion out Shedule A (Form 990 or 990-EZ) nd its instrutions is t An orgniztion orgnized nd operted exlusively to test for puli sfety. See setion 09()(). An orgniztion orgnized nd operted exlusively for the enefit of, to perform the funtions of, or to rry out the purposes of one or more pulily supported orgniztions desried in setion 09()() or setion 09()(). See setion 09()(). Chek the ox in lines through d tht desries the type of supporting orgniztion nd omplete lines e, f, nd g. Type I. A supporting orgniztion operted, supervised, or ontrolled y its supported orgniztion(s), typilly y giving the supported orgniztion(s) the power to regulrly ppoint or elet mjority of the diretors or trustees of the supporting orgniztion. You must omplete Prt IV, Setions A nd B. Type II. A supporting orgniztion supervised or ontrolled in onnetion with its supported orgniztion(s), y hving ontrol or mngement of the supporting orgniztion vested in the sme persons tht ontrol or mnge the supported orgniztion(s). You must omplete Prt IV, Setions A nd C. Type III funtionlly integrted. A supporting orgniztion operted in onnetion with, nd funtionlly integrted with, its supported orgniztion(s) (see instrutions). You must omplete Prt IV, Setions A, D, nd E. Type III non-funtionlly integrted. A supporting orgniztion operted in onnetion with its supported orgniztion(s) tht is not funtionlly integrted. The orgniztion generlly must stisfy distriution requirement nd n ttentiveness requirement (see instrutions). You must omplete Prt IV, Setions A nd D, nd Prt V. e Chek this ox if the orgniztion reeived written determintion from the IRS tht it is Type I, Type II, Type III funtionlly integrted, or Type III non-funtionlly integrted supporting orgniztion. f Enter the numer of supported orgniztions... g Provide the following informtion out the supported orgniztion(s). (ii) EIN (iii) Type of orgniztion (desried on lines 0 ove (see instrutions)) (iv) Is the orgniztion listed in your governing doument? (v) Amount of monetry support (see instrutions) (vi) Amount of other support (see instrutions) (B) (C) (D) (E) Totl For Pperwork Redution At tie, see the Instrutions for Form 990 or 990-EZ. Shedule A (Form 990 or 990-EZ) 0

15 Shedule A (Form 990 or 990-EZ) 0 Prt II Support Shedule for Orgniztions Desried in Setions 70()()(A)(iv) nd 70()()(A)(vi) (Complete only if you heked the ox on line, 7, or 8 of Prt I or if the orgniztion filed to qulify under Prt III. If the orgniztion fils to qulify under the tests listed elow, plese omplete Prt III.) Setion A. Puli Support Clendr yer (or fisl yer eginning in) u () 0 () 0 () 0 (d) 0 (e) 0 (f) Totl Pge Gifts, grnts, ontriutions, nd memership fees reeived. (Do not inlude ny "unusul grnts.")... Tx revenues levied for the orgniztion's enefit nd either pid to or expended on its ehlf..... The vlue of servies or filities furnished y governmentl unit to the orgniztion without hrge Totl. Add lines through..... The portion of totl ontriutions y eh person (other thn governmentl unit or pulily supported orgniztion) inluded on line tht exeeds % of the mount shown on line, olumn (f)..... Puli support. Sutrt line from line. Setion B. Totl Support Clendr yer (or fisl yer eginning in) u 7 8 Amounts from line Gross inome from interest, dividends, pyments reeived on seurities lons, rents, roylties nd inome from similr soures () 0 () 0 () 0 (d) 0 (e) 0 (f) Totl 9 0 Net inome from unrelted usiness tivities, whether or not the usiness is regulrly rried on..... Other inome. Do not inlude gin or loss from the sle of pitl ssets (Explin in Prt VI.) Totl support. Add lines 7 through 0 Gross reeipts from relted tivities, et. (see instrutions) First five yers. If the Form 990 is for the orgniztion s first, seond, third, fourth, or fifth tx yer s setion 0()() orgniztion, hek this ox nd stop here. Setion C. Computtion of Puli Support Perentge Puli support perentge for 0 (line, olumn (f) divided y line, olumn (f)).. Puli support perentge from 0 Shedule A, Prt II, line. /% support test 0. If the orgniztion did not hek the ox on line, nd line is /% or more, hek this % % 7 ox nd stop here. The orgniztion qulifies s pulily supported orgniztion.. /% support test 0. If the orgniztion did not hek ox on line or, nd line is /% or more, hek this ox nd stop here. The orgniztion qulifies s pulily supported orgniztion.... 0%-fts-nd-irumstnes test 0. If the orgniztion did not hek ox on line,, or, nd line is 0% or more, nd if the orgniztion meets the "fts-nd-irumstnes" test, hek this ox nd stop here. Explin in Prt VI how the orgniztion meets the "fts-nd-irumstnes" test. The orgniztion qulifies s pulily supported orgniztion %-fts-nd-irumstnes test 0. If the orgniztion did not hek ox on line,,, or 7, nd line is 0% or more, nd if the orgniztion meets the "fts-nd-irumstnes" test, hek this ox nd stop here. Explin in Prt VI how the orgniztion meets the "fts-nd-irumstnes" test. The orgniztion qulifies s pulily supported orgniztion.. 8 Privte foundtion. If the orgniztion did not hek ox on line,,, 7, or 7, hek this ox nd see instrutions Shedule A (Form 990 or 990-EZ) 0

16 Shedule A (Form 990 or 990-EZ) 0 Pge Prt III Support Shedule for Orgniztions Desried in Setion 09()() (Complete only if you heked the ox on line 0 of Prt I or if the orgniztion filed to qulify under Prt II. If the orgniztion fils to qulify under the tests listed elow, plese omplete Prt II.) Setion A. Puli Support Clendr yer (or fisl yer eginning in) u () 0 () 0 () 0 (d) 0 (e) 0 (f) Totl Gifts, grnts, ontriutions, nd memership fees reeived. (Do not inlude ny "unusul grnts.")... Gross reeipts from dmissions, merhndise sold or servies performed, or filities furnished in ny tivity tht is relted to the orgniztion s tx-exempt purpose... Gross reeipts from tivities tht re not n unrelted trde or usiness under setion Tx revenues levied for the orgniztion's enefit nd either pid to or expended on its ehlf..... The vlue of servies or filities furnished y governmentl unit to the orgniztion without hrge Totl. Add lines through..... Amounts inluded on lines,, nd reeived from disqulified persons Amounts inluded on lines nd reeived from other thn disqulified persons tht exeed the greter of,000 or % of the mount on line for the yer... Add lines 7 nd 7 8 Puli support. (Sutrt line 7 from line.) Setion B. Totl Support Clendr yer (or fisl yer eginning in) u 9 Amounts from line () 0 () 0 () 0 (d) 0 (e) 0 (f) Totl 0 Gross inome from interest, dividends, pyments reeived on seurities lons, rents, roylties nd inome from similr soures.... Unrelted usiness txle inome (less setion txes) from usinesses quired fter June 0, Add lines 0 nd Net inome from unrelted usiness tivities not inluded in line 0, whether or not the usiness is regulrly rried on.... Other inome. Do not inlude gin or loss from the sle of pitl ssets (Explin in Prt VI.) Totl support. (Add lines 9, 0,, nd.)..... First five yers. If the Form 990 is for the orgniztion s first, seond, third, fourth, or fifth tx yer s setion 0()() orgniztion, hek this ox nd stop here Setion C. Computtion of Puli Support Perentge Puli support perentge for 0 (line 8, olumn (f) divided y line, olumn (f)).. Puli support perentge from 0 Shedule A, Prt III, line Setion D. Computtion of Investment Inome Perentge Investment inome perentge for 0 (line 0, olumn (f) divided y line, olumn (f)). Investment inome perentge from 0 Shedule A, Prt III, line 7.. /% support tests 0. If the orgniztion did not hek the ox on line, nd line is more thn /%, nd line 7 is not more thn /%, hek this ox nd stop here. The orgniztion qulifies s pulily supported orgniztion /% support tests 0. If the orgniztion did not hek ox on line or line 9, nd line is more thn /%, nd line 8 is not more thn /%, hek this ox nd stop here. The orgniztion qulifies s pulily supported orgniztion... 0 Privte foundtion. If the orgniztion did not hek ox on line, 9, or 9, hek this ox nd see instrutions % % % % Shedule A (Form 990 or 990-EZ) 0

17 Shedule A (Form 990 or 990-EZ) 0 Pge Prt IV Supporting Orgniztions (Complete only if you heked ox in line on Prt I. If you heked of Prt I, omplete Setions A nd B. If you heked of Prt I, omplete Setions A nd C. If you heked of Prt I, omplete Setions A, D, nd E. If you heked d of Prt I, omplete Setions A nd D, nd omplete Prt V.) Setion A. All Supporting Orgniztions Are ll of the orgniztion s supported orgniztions listed y nme in the orgniztion s governing douments? If "," desrie in Prt VI how the supported orgniztions re designted. If designted y lss or purpose, desrie the designtion. If histori nd ontinuing reltionship, explin. Did the orgniztion hve ny supported orgniztion tht does not hve n IRS determintion of sttus under setion 09()() or ()? If "," explin in Prt VI how the orgniztion determined tht the supported orgniztion ws desried in setion 09()() or (). Did the orgniztion hve supported orgniztion desried in setion 0()(), (), or ()? If "," nswer () nd () elow. Did the orgniztion onfirm tht eh supported orgniztion qulified under setion 0()(), (), or () nd stisfied the puli support tests under setion 09()()? If "," desrie in Prt VI when nd how the orgniztion mde the determintion. Did the orgniztion ensure tht ll support to suh orgniztions ws used exlusively for setion 70()()(B) purposes? If "," explin in Prt VI wht ontrols the orgniztion put in ple to ensure suh use. Ws ny supported orgniztion not orgnized in the United Sttes ("foreign supported orgniztion")? If "," nd if you heked or in Prt I, nswer () nd () elow. Did the orgniztion hve ultimte ontrol nd disretion in deiding whether to mke grnts to the foreign supported orgniztion? If "," desrie in Prt VI how the orgniztion hd suh ontrol nd disretion despite eing ontrolled or supervised y or in onnetion with its supported orgniztions. Did the orgniztion support ny foreign supported orgniztion tht does not hve n IRS determintion under setions 0()() nd 09()() or ()? If "," explin in Prt VI wht ontrols the orgniztion used to ensure tht ll support to the foreign supported orgniztion ws used exlusively for setion 70()()(B) purposes. Did the orgniztion dd, sustitute, or remove ny supported orgniztions during the tx yer? If "," nswer () nd () elow (if pplile). Also, provide detil in Prt VI, inluding (i) the nmes nd EIN numers of the supported orgniztions dded, sustituted, or removed; (ii) the resons for eh suh tion; (iii) the uthority under the orgniztion's orgnizing doument uthorizing suh tion; nd (iv) how the tion ws omplished (suh s y mendment to the orgnizing doument). Type I or Type II only. Ws ny dded or sustituted supported orgniztion prt of lss lredy designted in the orgniztion's orgnizing doument? Sustitutions only. Ws the sustitution the result of n event eyond the orgniztion's ontrol? Did the orgniztion provide support (whether in the form of grnts or the provision of servies or filities) to nyone other thn (i) its supported orgniztions, (ii) individuls tht re prt of the hritle lss enefited y one or more of its supported orgniztions, or (iii) other supporting orgniztions tht lso support or enefit one or more of the filing orgniztion s supported orgniztions? If "," provide detil in Prt VI. Did the orgniztion provide grnt, lon, ompenstion, or other similr pyment to sustntil ontriutor (defined in setion 98()()(C)), fmily memer of sustntil ontriutor, or % ontrolled entity with regrd to sustntil ontriutor? If "," omplete Prt I of Shedule L (Form 990 or 990-EZ). Did the orgniztion mke lon to disqulified person (s defined in setion 98) not desried in line 7? If "," omplete Prt I of Shedule L (Form 990 or 990-EZ). Ws the orgniztion ontrolled diretly or indiretly t ny time during the tx yer y one or more disqulified persons s defined in setion 9 (other thn foundtion mngers nd orgniztions desried in setion 09()() or ())? If "," provide detil in Prt VI. Did one or more disqulified persons (s defined in line 9) hold ontrolling interest in ny entity in whih the supporting orgniztion hd n interest? If "," provide detil in Prt VI. Did disqulified person (s defined in line 9) hve n ownership interest in, or derive ny personl enefit from, ssets in whih the supporting orgniztion lso hd n interest? If "," provide detil in Prt VI. Ws the orgniztion sujet to the exess usiness holdings rules of setion 9 euse of setion 9(f) (regrding ertin Type II supporting orgniztions, nd ll Type III non-funtionlly integrted supporting orgniztions)? If "," nswer 0 elow. Did the orgniztion hve ny exess usiness holdings in the tx yer? (Use Shedule C, Form 70, to determine whether the orgniztion hd exess usiness holdings.) Shedule A (Form 990 or 990-EZ) 0

18 Shedule A (Form 990 or 990-EZ) 0 Pge Prt IV Supporting Orgniztions (ontinued) Hs the orgniztion epted gift or ontriution from ny of the following persons? A person who diretly or indiretly ontrols, either lone or together with persons desried in () nd () elow, the governing ody of supported orgniztion? A fmily memer of person desried in () ove? A % ontrolled entity of person desried in () or () ove? If "" to,, or, provide detil in Prt VI. Setion B. Type I Supporting Orgniztions Did the diretors, trustees, or memership of one or more supported orgniztions hve the power to regulrly ppoint or elet t lest mjority of the orgniztion s diretors or trustees t ll times during the tx yer? If "," desrie in Prt VI how the supported orgniztion(s) effetively operted, supervised, or ontrolled the orgniztion s tivities. If the orgniztion hd more thn one supported orgniztion, desrie how the powers to ppoint nd/or remove diretors or trustees were lloted mong the supported orgniztions nd wht onditions or restritions, if ny, pplied to suh powers during the tx yer. Did the orgniztion operte for the enefit of ny supported orgniztion other thn the supported orgniztion(s) tht operted, supervised, or ontrolled the supporting orgniztion? If "," explin in Prt VI how providing suh enefit rried out the purposes of the supported orgniztion(s) tht operted, supervised, or ontrolled the supporting orgniztion. Setion C. Type II Supporting Orgniztions Were mjority of the orgniztion s diretors or trustees during the tx yer lso mjority of the diretors or trustees of eh of the orgniztion s supported orgniztion(s)? If "," desrie in Prt VI how ontrol or mngement of the supporting orgniztion ws vested in the sme persons tht ontrolled or mnged the supported orgniztion(s). Setion D. All Type III Supporting Orgniztions Did the orgniztion provide to eh of its supported orgniztions, y the lst dy of the fifth month of the orgniztion s tx yer, (i) written notie desriing the type nd mount of support provided during the prior tx yer, (ii) opy of the Form 990 tht ws most reently filed s of the dte of notifition, nd (iii) opies of the orgniztion s governing douments in effet on the dte of notifition, to the extent not previously provided? Were ny of the orgniztion s offiers, diretors, or trustees either (i) ppointed or eleted y the supported orgniztion(s) or (ii) serving on the governing ody of supported orgniztion? If "," explin in Prt VI how the orgniztion mintined lose nd ontinuous working reltionship with the supported orgniztion(s). By reson of the reltionship desried in (), did the orgniztion s supported orgniztions hve signifint voie in the orgniztion s investment poliies nd in direting the use of the orgniztion s inome or ssets t ll times during the tx yer? If "," desrie in Prt VI the role the orgniztion s supported orgniztions plyed in this regrd. Setion E. Type III Funtionlly-Integrted Supporting Orgniztions Chek the ox next to the method tht the orgniztion used to stisfy the Integrl Prt Test during the yer (see instrutions). The orgniztion stisfied the Ativities Test. Complete line elow. The orgniztion is the prent of eh of its supported orgniztions. Complete line elow. The orgniztion supported governmentl entity. Desrie in Prt VI how you supported government entity (see instrutions). Ativities Test. Answer () nd () elow. Did sustntilly ll of the orgniztion s tivities during the tx yer diretly further the exempt purposes of the supported orgniztion(s) to whih the orgniztion ws responsive? If "," then in Prt VI identify those supported orgniztions nd explin how these tivities diretly furthered their exempt purposes, how the orgniztion ws responsive to those supported orgniztions, nd how the orgniztion determined tht these tivities onstituted sustntilly ll of its tivities. Did the tivities desried in () onstitute tivities tht, ut for the orgniztion s involvement, one or more of the orgniztion s supported orgniztion(s) would hve een engged in? If "," explin in Prt VI the resons for the orgniztion s position tht its supported orgniztion(s) would hve engged in these tivities ut for the orgniztion s involvement. Prent of Supported Orgniztions. Answer () nd () elow. Did the orgniztion hve the power to regulrly ppoint or elet mjority of the offiers, diretors, or trustees of eh of the supported orgniztions? Provide detils in Prt VI. Did the orgniztion exerise sustntil degree of diretion over the poliies, progrms, nd tivities of eh of its supported orgniztions? If "," desrie in Prt VI the role plyed y the orgniztion in this regrd. Shedule A (Form 990 or 990-EZ) 0

19 Shedule A (Form 990 or 990-EZ) 0 Pge Prt V Type III n-funtionlly Integrted 09()() Supporting Orgniztions Chek here if the orgniztion stisfied the Integrl Prt Test s qulifying trust on v. 0, 970 (explin in Prt VI).See instrutions. All other Type III non-funtionlly integrted supporting orgniztions must omplete Setions A through E. Setion A - Adjusted Net Inome (A) Prior Yer (B) Current Yer (optionl) Net short-term pitl gin Reoveries of prior-yer distriutions Other gross inome (see instrutions) Add lines through. Depreition nd depletion Portion of operting expenses pid or inurred for prodution or olletion of gross inome or for mngement, onservtion, or mintenne of property held for prodution of inome (see instrutions) 7 8 Other expenses (see instrutions) Adjusted Net Inome (sutrt lines, nd 7 from line ). 7 8 Setion B - Minimum Asset Amount (A) Prior Yer (B) Current Yer (optionl) Aggregte fir mrket vlue of ll non-exempt-use ssets (see instrutions for short tx yer or ssets held for prt of yer): d e Averge monthly vlue of seurities Averge monthly sh lnes Fir mrket vlue of other non-exempt-use ssets Totl (dd lines,, nd ) Disount limed for lokge or other d ftors (explin in detil in Prt VI): Aquisition indetedness pplile to non-exempt-use ssets Sutrt line from line d. Csh deemed held for exempt use. Enter -/% of line (for greter mount, see instrutions). 7 8 Net vlue of non-exempt-use ssets (sutrt line from line ) Multiply line y.0. Reoveries of prior-yer distriutions Minimum Asset Amount (dd line 7 to line ) 7 8 Setion C - Distriutle Amount Current Yer Adjusted net inome for prior yer (from Setion A, line 8, Column A) Enter 8% of line. Minimum sset mount for prior yer (from Setion B, line 8, Column A) Enter greter of line or line. Inome tx imposed in prior yer Distriutle Amount. Sutrt line from line, unless sujet to emergeny temporry redution (see instrutions). 7 Chek here if the urrent yer is the orgniztion's first s non-funtionlly integrted Type III supporting orgniztion (see instrutions). Shedule A (Form 990 or 990-EZ) 0

20 Shedule A (Form 990 or 990-EZ) 0 Pge 7 Prt V Type III n-funtionlly Integrted 09()() Supporting Orgniztions (ontinued) Setion D - Distriutions Current Yer Amounts pid to supported orgniztions to omplish exempt purposes Amounts pid to perform tivity tht diretly furthers exempt purposes of supported orgniztions, in exess of inome from tivity Administrtive expenses pid to omplish exempt purposes of supported orgniztions Amounts pid to quire exempt-use ssets Qulified set-side mounts (prior IRS pprovl required) Other distriutions (desrie in Prt VI). See instrutions. 7 Totl nnul distriutions. Add lines through. 8 Distriutions to ttentive supported orgniztions to whih the orgniztion is responsive (provide detils in Prt VI). See instrutions. 9 Distriutle mount for 0 from Setion C, line 0 Line 8 mount divided y Line 9 mount (i) (ii) (iii) Setion E - Distriution Allotions (see instrutions) Exess Distriutions Underdistriutions Distriutle Pre-0 Amount for 0 Distriutle mount for 0 from Setion C, line Underdistriutions, if ny, for yers prior to 0 (resonle use required-explin in Prt VI). See instrutions. Exess distriutions rryover, if ny, to 0: From d From 0 e From 0 f Totl of lines through e g Applied to underdistriutions of prior yers h Applied to 0 distriutle mount i Crryover from 0 not pplied (see instrutions) j Reminder. Sutrt lines g, h, nd i from f. Distriutions for 0 from Setion D, line 7: Applied to underdistriutions of prior yers Applied to 0 distriutle mount Reminder. Sutrt lines nd from. Remining underdistriutions for yers prior to 0, if ny. Sutrt lines g nd from line. For result greter thn zero, explin in Prt VI. See instrutions. Remining underdistriutions for 0. Sutrt lines h nd from line. For result greter thn zero, explin in Prt VI. See instrutions. 7 Exess distriutions rryover to 07. Add lines j nd. 8 Brekdown of line 7: Exess from Exess from d Exess from e Exess from Shedule A (Form 990 or 990-EZ) 0

21 Shedule A (Form 990 or 990-EZ) 0 Prt VI Supplementl Informtion. Provide the explntions required y Prt II, line 0; Prt II, line 7 or 7; Prt III, line ; Prt IV, Setion A, lines,,,,,,,, 9, 9, 9,,, nd ; Prt IV, Setion B, lines nd ; Prt IV, Setion C, line ; Prt IV, Setion D, lines nd ; Prt IV, Setion E, lines,,, nd ; Prt V, line ; Prt V, Setion B, line e; Prt V, Setion D, lines,, nd 8; nd Prt V, Setion E, lines,, nd. Also omplete this prt for ny dditionl informtion. (See instrutions.) Pge 8 Shedule A (Form 990 or 990-EZ) 0

22 Shedule B (Form 990, 990-EZ, or 990-PF) Deprtment of the Tresury Internl Revenue Servie Nme of the orgniztion Shedule of Contriutors u Atth to Form 990, Form 990-EZ, or Form 990-PF. u Informtion out Shedule B (Form 990, 990-EZ, or 990-PF) nd its instrutions is t OMB Employer identifition numer Orgniztion type (hek one): Filers of: Setion: Form 990 or 990-EZ 0()( ) (enter numer) orgniztion 97()() nonexempt hritle trust not treted s privte foundtion 7 politil orgniztion Form 990-PF 0()() exempt privte foundtion 97()() nonexempt hritle trust treted s privte foundtion 0()() txle privte foundtion Chek if your orgniztion is overed y the Generl Rule or Speil Rule. te: Only setion 0()(7), (8), or (0) orgniztion n hek oxes for oth the Generl Rule nd Speil Rule. See instrutions. Generl Rule For n orgniztion filing Form 990, 990-EZ, or 990-PF tht reeived, during the yer, ontriutions totling,000 or more (in money or property) from ny one ontriutor. Complete Prts I nd II. See instrutions for determining ontriutor's totl ontriutions. Speil Rules For n orgniztion desried in setion 0()() filing Form 990 or 990-EZ tht met the / % support test of the regultions under setions 09()() nd 70()()(A)(vi), tht heked Shedule A (Form 990 or 990-EZ), Prt II, line,, or, nd tht reeived from ny one ontriutor, during the yer, totl ontriutions of the greter of (),000 or () % of the mount on (i) Form 990, Prt VIII, line h, or (ii) Form 990-EZ, line. Complete Prts I nd II. For n orgniztion desried in setion 0()(7), (8), or (0) filing Form 990 or 990-EZ tht reeived from ny one ontriutor, during the yer, totl ontriutions of more thn,000 exlusively for religious, hritle, sientifi, literry, or edutionl purposes, or for the prevention of ruelty to hildren or nimls. Complete Prts I, II, nd III. For n orgniztion desried in setion 0()(7), (8), or (0) filing Form 990 or 990-EZ tht reeived from ny one ontriutor, during the yer, ontriutions exlusively for religious, hritle, et., purposes, ut no suh ontriutions totled more thn,000. If this ox is heked, enter here the totl ontriutions tht were reeived during the yer for n exlusively religious, hritle, et., purpose. Don't omplete ny of the prts unless the Generl Rule pplies to this orgniztion euse it reeived nonexlusively religious, hritle, et., ontriutions totling,000 or more during the yer Cution: An orgniztion tht isn't overed y the Generl Rule nd/or the Speil Rules doesn't file Shedule B (Form 990, 990-EZ, or 990-PF), ut it must nswer on Prt IV, line, of its Form 990; or hek the ox on line H of its Form 990-EZ or on its Form 990-PF, Prt I, line, to ertify tht it doesn't meet the filing requirements of Shedule B (Form 990, 990-EZ, or 990-PF). For Pperwork Redution At tie, see the Instrutions for Form 990, 990-EZ, or 990-PF. Shedule B (Form 990, 990-EZ, or 990-PF) (0)

23 Shedule B (Form 990, 990-EZ, or 990-PF) (0) Nme of orgniztion LAKELAND VOLUNTEERS IN MEDICINE INC PAGE OF Employer identifition numer -0 Prt I Contriutors (See instrutions). Use duplite opies of Prt I if dditionl spe is needed. () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution Pge BURNETTI CHILDREN'S FOUNDATION S FLORIDA AVENUE LAKELAND FL 80 0,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution CITY OF LAKELAND 9 N MASSACHUSETTS AVENUE LAKELAND FL 80,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution HARRELL'S FERTILIZER GROUP, INC. PO BO 807 LAKELAND FL 80 0,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution GEORGE HUDSON 9 CAMELOT LANE LAKELAND FL 8,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution DELTA DENTAL COMMUNITY CARE FNDN ONE DELTA DR MECHANICSBURG PA 70,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution JOHN A LEIGHTY FUND LAKE MORTON DRIVE LAKELAND FL 80 0,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) Shedule B (Form 990, 990-EZ, or 990-PF) (0)

24 Shedule B (Form 990, 990-EZ, or 990-PF) (0) Nme of orgniztion LAKELAND VOLUNTEERS IN MEDICINE INC PAGE OF Employer identifition numer -0 Prt I Contriutors (See instrutions). Use duplite opies of Prt I if dditionl spe is needed. () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution Pge 7 POLK CO BD OF CO COMMISSIONERS DRAWER AS07, PO BO 900 BARTOW FL 8 9,0 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution 8 ROOMS TO GO 0 US HWY 9 EAST SEFFNER FL 8 0,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution 9 SANLAN RV & GOLF RESORT 0 MEADOWBROOK AVE. LAKELAND FL 80,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution 0 UNITED WAY OF CENTRAL FLORIDA PO BO 7 HIGHLAND CITY FL 8 8,88 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution STEVE PETERSON 0 CALUSAJA DR VALRICO FL 9-8 8, Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution WELLDYNER 00 EAGLES LANDING DR LAKELAND FL 80 7,00 Pyroll nsh (Complete Prt II for nonsh ontriutions.) Shedule B (Form 990, 990-EZ, or 990-PF) (0)

25 Shedule B (Form 990, 990-EZ, or 990-PF) (0) Nme of orgniztion LAKELAND VOLUNTEERS IN MEDICINE INC PAGE OF Employer identifition numer -0 Prt I Contriutors (See instrutions). Use duplite opies of Prt I if dditionl spe is needed. () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution Pge BRUCE R ABELS NEVADA ROAD LAKELAND FL 80 7,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution BANK OF AMERICA S. FLORIDA AVENUE LAKELAND FL 80-,09 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution. FLORIDA... ASSN.... OF FREE CHARITABLE... CLI.... PO BO 977 ST. PETERSBURG FL 7 7,700 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution GIVE WELL COMMUNITY FNDN 0 S FLORIDA AVE LAKELAND FL 80-8,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution 7 ANNE O WATKINS PO BO 890 LAKELAND FL 80 7,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution 8 LOUISE WATKINS PO BO 890 LAKELAND FL 80,0 Pyroll nsh (Complete Prt II for nonsh ontriutions.) Shedule B (Form 990, 990-EZ, or 990-PF) (0)

26 Shedule B (Form 990, 990-EZ, or 990-PF) (0) Nme of orgniztion LAKELAND VOLUNTEERS IN MEDICINE INC PAGE OF Employer identifition numer -0 Prt I Contriutors (See instrutions). Use duplite opies of Prt I if dditionl spe is needed. () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution Pge 9 HOYT R. BARNETT 8 LIVE OAK ROAD LAKELAND FL 8,00 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution 0 GLENN W. & HAZELLE PASON MORRISON FOUNDATION P.O. BO 78 LAKELAND FL 807,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution VITAS HEALTHCARE 80 NEW TAMPA HWY., STE. 00 LAKELAND FL 8,000 Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution Pyroll nsh (Complete Prt II for nonsh ontriutions.) () () () (d). Nme, ddress, nd ZIP + Totl ontriutions Type of ontriution Pyroll nsh (Complete Prt II for nonsh ontriutions.) Shedule B (Form 990, 990-EZ, or 990-PF) (0)

27 SCHEDULE D (Form 990) Deprtment of the Tresury Internl Revenue Servie Nme of the orgniztion Supplementl Finnil Sttements u Complete if the orgniztion nswered on Form 990, Prt IV, line, 7, 8, 9, 0,,,, d, e, f,, or. u Atth to Form 990. u Informtion out Shedule D (Form 990) nd its instrutions is t Employer identifition numer OMB Open to Puli Inspetion Prt I Orgniztions Mintining Donor Advised Funds or Other Similr Funds or Aounts. Complete if the orgniztion nswered on Form 990, Prt IV, line. () Donor dvised funds () Funds nd other ounts onferring impermissile privte enefit?.... Prt II Conservtion Esements. Complete if the orgniztion nswered on Form 990, Prt IV, line 7. d Totl numer t end of yer. Aggregte vlue of ontriutions to (during yer) Aggregte vlue of grnts from (during yer).... Aggregte vlue t end of yer..... Did the orgniztion inform ll donors nd donor dvisors in writing tht the ssets held in donor dvised funds re the orgniztion s property, sujet to the orgniztion s exlusive legl ontrol?. Did the orgniztion inform ll grntees, donors, nd donor dvisors in writing tht grnt funds n e used only for hritle purposes nd not for the enefit of the donor or donor dvisor, or for ny other purpose Purpose(s) of onservtion esements held y the orgniztion (hek ll tht pply). Preservtion of lnd for puli use (e.g., reretion or edution) Protetion of nturl hitt Preservtion of open spe Preservtion of historilly importnt lnd re Preservtion of ertified histori struture Complete lines through d if the orgniztion held qulified onservtion ontriution in the form of onservtion esement on the lst dy of the tx yer. Totl numer of onservtion esements Totl rege restrited y onservtion esements. Numer of onservtion esements on ertified histori struture inluded in ()..... Numer of onservtion esements inluded in () quired fter 8/7/0, nd not on histori struture listed in the Ntionl Register d Numer of onservtion esements modified, trnsferred, relesed, extinguished, or terminted y the orgniztion during the Held t the End of the Tx Yer tx yer u.. Numer of sttes where property sujet to onservtion esement is loted u. Does the orgniztion hve written poliy regrding the periodi monitoring, inspetion, hndling of violtions, nd enforement of the onservtion esements it holds?... Stff nd volunteer hours devoted to monitoring, inspeting, hndling of violtions, nd enforing onservtion esements during the yer 7 Amount of expenses inurred in monitoring, inspeting, hndling of violtions, nd enforing onservtion esements during the yer u Does eh onservtion esement reported on line (d) ove stisfy the requirements of setion 70(h)()(B)(i) nd setion 70(h)()(B)(ii)? In Prt III, desrie how the orgniztion reports onservtion esements in its revenue nd expense sttement, nd lne sheet, nd inlude, if pplile, the text of the footnote to the orgniztion s finnil sttements tht desries the orgniztion s ounting for onservtion esements. Prt III Orgniztions Mintining Colletions of Art, Historil Tresures, or Other Similr Assets. Complete if the orgniztion nswered on Form 990, Prt IV, line 8. If the orgniztion eleted, s permitted under SFAS (ASC 98), not to report in its revenue sttement nd lne sheet works of rt, historil tresures, or other similr ssets held for puli exhiition, edution, or reserh in furtherne of puli servie, provide, in Prt III, the text of the footnote to its finnil sttements tht desries these items. If the orgniztion eleted, s permitted under SFAS (ASC 98), to report in its revenue sttement nd lne sheet works of rt, historil tresures, or other similr ssets held for puli exhiition, edution, or reserh in furtherne of puli servie, provide the following mounts relting to these items: (i) Revenue inluded on Form 990, Prt VIII, line u (ii) Assets inluded in Form 990, Prt.... u If the orgniztion reeived or held works of rt, historil tresures, or other similr ssets for finnil gin, provide the following mounts required to e reported under SFAS (ASC 98) relting to these items: Revenue inluded on Form 990, Prt VIII, line... Assets inluded in Form 990, Prt. For Pperwork Redution At tie, see the Instrutions for Form 990. u.. u u Shedule D (Form 990) 0

28 Shedule D (Form 990) 0 Pge Prt III Orgniztions Mintining Colletions of Art, Historil Tresures, or Other Similr Assets (ontinued) Using the orgniztion s quisition, ession, nd other reords, hek ny of the following tht re signifint use of its olletion items (hek ll tht pply): Puli exhiition d Lon or exhnge progrms Sholrly reserh e Other Preservtion for future genertions Provide desription of the orgniztion s olletions nd explin how they further the orgniztion s exempt purpose in Prt III. During the yer, did the orgniztion soliit or reeive dontions of rt, historil tresures, or other similr ssets to e sold to rise funds rther thn to e mintined s prt of the orgniztion s olletion?..... Prt IV Esrow nd Custodil Arrngements. Complete if the orgniztion nswered "" on Form 990, Prt IV, line 9, or reported n mount on Form 990, Prt, line. Is the orgniztion n gent, trustee, ustodin or other intermediry for ontriutions or other ssets not inluded on Form 990, Prt?. If, explin the rrngement in Prt III nd omplete the following tle: Amount Beginning lne.... d Additions during the yer.... d e Distriutions during the yer. e f Ending lne f Did the orgniztion inlude n mount on Form 990, Prt, line, for esrow or ustodil ount liility?.. If, explin the rrngement in Prt III. Chek here if the explntion hs een provided on Prt III.. Prt V Endowment Funds. Complete if the orgniztion nswered on Form 990, Prt IV, line 0. Beginning of yer lne. Contriutions Net investment ernings, gins, nd losses. d Grnts or sholrships.... e Other expenditures for filities nd () Current yer () Prior yer () Two yers k (d) Three yers k (e) Four yers k f progrms.... Administrtive expenses.. g End of yer lne Provide the estimted perentge of the urrent yer end lne (line g, olumn ()) held s: Bord designted or qusi-endowment u. % Permnent endowment u. % Temporrily restrited endowment u. % The perentges on lines,, nd should equl 00%. Are there endowment funds not in the possession of the orgniztion tht re held nd dministered for the orgniztion y: (i) (ii) unrelted orgniztions.... relted orgniztions (i) (ii) If on line (ii), re the relted orgniztions listed s required on Shedule R? Desrie in Prt III the intended uses of the orgniztion s endowment funds. Prt VI Lnd, Buildings, nd Equipment. Complete if the orgniztion nswered on Form 990, Prt IV, line. See Form 990, Prt, line 0. d Desription of property Lnd Buildings.. Lesehold improvements Equipment () Cost or other sis (investment) () Cost or other sis (other) () Aumulted depreition e Other..... Totl. Add lines through e. (Column (d) must equl Form 990, Prt, olumn (B), line 0.).... u (d) Book vlue,00,00,99,99 8,70,7,79 9,0,78 7,97,,,,9,7 Shedule D (Form 990) 0

29 Shedule D (Form 990) 0 Prt VII Investments Other Seurities. Complete if the orgniztion nswered on Form 990, Prt IV, line. See Form 990, Prt, line. () () () () Desription of seurity or tegory (inluding nme of seurity) Finnil derivtives.... Closely-held equity interests... Other () Book vlue () Method of vlution: Cost or end-of-yer mrket vlue Totl. (Column () must equl Form 990, Prt, ol. (B) line.) u Prt VIII Investments Progrm Relted. Complete if the orgniztion nswered on Form 990, Prt IV, line. See Form 990, Prt, line. () Desription of investment () Book vlue () Method of vlution: Cost or end-of-yer mrket vlue Totl. (Column () must equl Form 990, Prt, ol. (B) line.) u Prt I Other Assets. Complete if the orgniztion nswered on Form 990, Prt IV, line d. See Form 990, Prt, line. (A) (B) (C) (D) (E) (F) (G) (H).. () () () () () () (7) (8) (9) () () () () () () (7) (8) () Desription () Book vlue (9) Totl. (Column () must equl Form 990, Prt, ol. (B) line.) u Prt Other Liilities. Complete if the orgniztion nswered "" on Form 990, Prt IV, line e or f. See Form 990, Prt, line.. () Desription of liility () Book vlue () () () () () () (7) (8) (9) Federl inome txes Totl. (Column () must equl Form 990, Prt, ol. (B) line.) u. Liility for unertin tx positions. In Prt III, provide the text of the footnote to the orgniztion s finnil sttements tht reports the orgniztion's liility for unertin tx positions under FIN 8 (ASC 70). Chek here if the text of the footnote hs een provided in Prt III.... Pge OTHERS,98,90 PREPAID INSURANCE, DEPOSITS,8 BENEFICIAL INTEREST-ASSETS HELD BY,77,08 Shedule D (Form 990) 0

30 Shedule D (Form 990) 0 Prt I Reonilition of Revenue per Audited Finnil Sttements With Revenue per Return. Complete if the orgniztion nswered on Form 990, Prt IV, line. Totl revenue, gins, nd other support per udited finnil sttements..... Amounts inluded on line ut not on Form 990, Prt VIII, line : d e Net unrelized gins (losses) on investments Donted servies nd use of filities. Reoveries of prior yer grnts. Other (Desrie in Prt III.)... Add lines through d Sutrt line e from line.... Amounts inluded on Form 990, Prt VIII, line, ut not on line : Investment expenses not inluded on Form 990, Prt VIII, line Other (Desrie in Prt III.)... Add lines nd.... Totl revenue. Add lines nd. (This must equl Form 990, Prt I, line.) Prt II Reonilition of Expenses per Audited Finnil Sttements With Expenses per Return. Complete if the orgniztion nswered "" on Form 990, Prt IV, line. Totl expenses nd losses per udited finnil sttements..... Amounts inluded on line ut not on Form 990, Prt I, line : d e Donted servies nd use of filities. Prior yer djustments.. Other losses Other (Desrie in Prt III.)... Add lines through d Sutrt line e from line.... Amounts inluded on Form 990, Prt I, line, ut not on line : Investment expenses not inluded on Form 990, Prt VIII, line Other (Desrie in Prt III.)... Add lines nd.... Totl expenses. Add lines nd. (This must equl Form 990, Prt I, line 8.).... Prt III Supplementl Informtion. Provide the desriptions required for Prt II, lines,, nd 9; Prt III, lines nd ; Prt IV, lines nd ; Prt V, line ; Prt, line ; Prt I, lines d nd ; nd Prt II, lines d nd. Also omplete this prt to provide ny dditionl informtion. d d 0,0 79,9,9 79,9,9 e e Pge,8, 79,89,78,,9,9,0,97, 79,9,8,0,9,0,98 Shedule D (Form 990) 0

31 Shedule D (Form 990) 0 Prt III Supplementl Informtion (ontinued) Pge Shedule D (Form 990) 0

32 SCHEDULE G (Form 990 or 990-EZ) Deprtment of the Tresury Internl Revenue Servie Nme of the orgniztion Supplementl Informtion Regrding Fundrising or Gming Ativities OMB Complete if the orgniztion nswered on Form 990, Prt IV, line 7, 8, or 9, or if the orgniztion entered more thn,000 on Form 990-EZ, line. 0 u Atth to Form 990 or Form 990-EZ. Open to Puli u Informtion out Shedule G (Form 990 or 990-EZ) nd its instrutions is t Inspetion Employer identifition numer Prt I Fundrising Ativities. Complete if the orgniztion nswered on Form 990, Prt IV, line 7. Form 990-EZ filers re not required to omplete this prt. Indite whether the orgniztion rised funds through ny of the following tivities. Chek ll tht pply. d Mil soliittions Internet nd emil soliittions Phone soliittions In-person soliittions Soliittion of non-government grnts Soliittion of government grnts Speil fundrising events Did the orgniztion hve written or orl greement with ny individul (inluding offiers, diretors, trustees, or key employees listed in Form 990, Prt VII) or entity in onnetion with professionl fundrising servies?. e f g If, list the 0 highest pid individuls or entities (fundrisers) pursunt to greements under whih the fundriser is to e ompensted t lest,000 y the orgniztion. (iii) Did fundol. (v) Amount pid to riser hve (i) Nme nd ddress of individul (iv) Gross reeipts (or retined y) or entity (fundriser) (ii) Ativity ustody or ontrol of from tivity fundriser listed in ontriutions? (i) (vi) Amount pid to (or retined y) orgniztion Totl. List ll sttes in whih the orgniztion is registered or liensed to soliit ontriutions or hs een notified it is exempt from registrtion or liensing.. For Pperwork Redution At tie, see the Instrutions for Form 990 or 990-EZ. Shedule G (Form 990 or 990-EZ) 0.

33 Shedule G (Form 990 or 990-EZ) 0 Pge Prt II Fundrising Events. Complete if the orgniztion nswered on Form 990, Prt IV, line 8, or reported more thn,000 of fundrising event ontriutions nd gross inome on Form 990-EZ, lines nd. List events with gross reeipts greter thn,000. Revenue Gross reeipts.. () Event # () Event # () Other events LAKELAND DERBY NONE (event type) (event type) (totl numer) (d) Totl events (dd ol. () through ol. ()),0,0 Less: Contriutions.... Gross inome (line minus line ).....,0,0 Csh prizes..... nsh prizes. Diret Expenses 7 8 Rent/fility osts..... Food nd everges.. Entertinment.. 9 Other diret expenses Diret Expenses Revenue 0 Diret expense summry. Add lines through 9 in olumn (d).. Net inome summry. Sutrt line 0 from line, olumn (d).. Prt III Gming. Complete if the orgniztion nswered on Form 990, Prt IV, line 9, or reported more thn,000 on Form 990-EZ, line. Gross revenue.. Csh prizes..... nsh prizes. Rent/fility osts.....,0 () Pull ts/instnt (d) Totl gming (dd () Bingo () Other gming ingo/progressive ingo ol. () through ol. ()) Other diret expenses Volunteer lor.... %.. % % 7 8 Diret expense summry. Add lines through in olumn (d).. Net gming inome summry. Sutrt line 7 from line, olumn (d).. 9 Enter the stte(s) in whih the orgniztion onduts gming tivities:... Is the orgniztion liensed to ondut gming tivities in eh of these sttes? If, explin: 0 Were ny of the orgniztion s gming lienses revoked, suspended, or terminted during the tx yer?... If, explin: Shedule G (Form 990 or 990-EZ) 0

34 Shedule G (Form 990 or 990-EZ) 0 Indite the perentge of gming tivity onduted in: The orgniztion s fility. An outside fility.. Enter the nme nd ddress of the person who prepres the orgniztion s gming/speil events ooks nd reords: Does the orgniztion ondut gming tivities with nonmemers?..... Is the orgniztion grntor, enefiiry or trustee of trust, or memer of prtnership or other entity formed to dminister hritle gming? Pge % % Nme u..... Address u... Does the orgniztion hve ontrt with third prty from whom the orgniztion reeives gming revenue?... If, enter the mount of gming revenue reeived y the orgniztion u mount of gming revenue retined y the third prty u If, enter nme nd ddress of the third prty:... nd the Nme u..... Address u... Gming mnger informtion: Nme u... Gming mnger ompenstion u Desription of servies provided u.... Diretor/offier Employee Independent ontrtor 7 Mndtory distriutions: Is the orgniztion required under stte lw to mke hritle distriutions from the gming proeeds to retin the stte gming liense?. Enter the mount of distriutions required under stte lw to e distriuted to other exempt orgniztions or spent in the orgniztion s own exempt tivities during the tx yer u Prt IV Supplementl Informtion. Provide the explntions required y Prt I, line, olumns (iii) nd (v); nd Prt III, lines 9, 9, 0,,,, nd 7, s pplile. Also provide ny dditionl informtion. See instrutions. Shedule G (Form 990 or 990-EZ) 0

35 SCHEDULE O (Form 990 or 990-EZ) Deprtment of the Tresury Internl Revenue Servie Nme of the orgniztion Supplementl Informtion to Form 990 or 990-EZ Complete to provide informtion for responses to speifi questions on Form 990 or 990-EZ or to provide ny dditionl informtion. OMB u Atth to Form 990 or 990-EZ. Open to Puli u Informtion out Shedule O (Form 990 or 990-EZ) nd its instrutions is t Inspetion Employer identifition numer FORM 990, PART III, LINE D - ALL OTHER ACCOMPLISHMENT TO PROVIDE MEDICAL CARE TO THE NEEDY IN THE LAKELAND AREA FORM 990, PART VI, LINE B - ORGANIZATION'S PROCESS TO REVIEW FORM TA RETURN IS PROVIDED TO THE MEMBERS VIA OR AT A BOARD MEETING PRIOR TO FILING. FORM 990, PART VI, LINE 9 - GOVERNING DOCUMENTS DISCLOSURE EPLANATION NO DOCUMENTS AVAILABLE TO THE PUBLIC For Pperwork Redution At tie, see the Instrutions for Form 990 or 990-EZ. Shedule O (Form 990 or 990-EZ) (0)

36 Nme Form 990 For lendr yer 0, or tx yer eginning Two Yer Comprison Report, ending 0 & 0 Txpyer Identifition Numer R e v e n u e E x p e n s e s Other Informtion. Contriutions, gifts, grnts Memership dues nd ssessments... Government ontriutions nd grnts.. Progrm servie revenue Investment inome Proeeds from tx exempt onds Net gin or (loss) from sle of ssets other thn inventory Net inome or (loss) from fundrising events Net inome or (loss) from gming Net gin or (loss) on sles of inventory Other revenue..... Totl revenue. Add lines through.. Grnts nd similr mounts pid Benefits pid to or for memers Compenstion of offiers, diretors, trustees, et.... Slries, other ompenstion, nd employee enefits Professionl fundrising fees Other professionl fees Oupny, rent, utilities, nd mintenne Depreition nd Depletion Other expenses... Totl expenses. Add lines through.... Exess or (Defiit). Sutrt line from line.. Totl exempt revenue.. Totl unrelted revenue.. Totl exludle revenue Totl ssets Totl liilities Retined ernings Numer of voting memers of governing ody Numer of independent voting memers of governing ody Numer of employees.... Numer of volunteers. 0 0 Differenes 79,7 7, -,9 98,78,0,,00,7,07,9, 9,80 0,99-0,99,,0, -,0,08,8,09,9,0 0,09 89,89 89,89,98 8, 9,87 00,8 9, -7,90 7,9 0,787,8 0,07 99, 9,,9,88,0,98 9,7 -,9 0,9,98,8,09,9,0 0,09-8, 88,88,99,87,00,00,7,70 0,70 9,9,88,8,0,9,0 0,

37 Form 990 Tx Return History 0 Nme Employer Identifition Numer Contriutions, gifts, grnts ,8,0 0 9,7 0,, ,090,009,7,7 Memership dues Progrm servie revenue Cpitl gin or loss Investment inome Fundrising revenue (inome/loss)... 98,00 89,9,08 8,7 7,7,8 7,0 7,8,00 0,99,9,,7,,0 Gming revenue (inome/loss) Other revenue.. Totl revenue....,00,00,9,8,,70, -,0,8,09,9,0 Grnts nd similr mounts pid..... Benefits pid to or for memers Compenstion of offiers, et.. Other ompenstion.... Professionl fees. 8,000,9 8,000 7,90 0,9 8,0,0 90, 89,89,98 00,8 89,89 8, 9, Oupny osts. Depreition nd depletion..... Other expenses.. Totl expenses.. Exess or (Defiit) ,,,9,0,7-8, 08,98 7,0,7,98 7,7,9,090,7,7 89,08 7,9 0,07,9,88 -,9 0,787 99,,0,98 0,9 Totl exempt revenue...,00,9,8,,70,,8,09,9,0 Totl unrelted revenue. Totl exludle revenue Totl Assets Totl Liilities... Net Fund Blnes......,00,9,7,,7,7,89,7,99,08 0,,88, 08,898,9,9 7,78,877,7-8,,87,00 0,70,8,0 88,88,00,7 9,9,9,0

38 Form Nme 990T Tx Return History 0 Employer Identifition Numer Business tivity profit/loss.. Cpitl gins/losses..... Prtner nd S Corp gin/loss.. Rentl inome*... Det-finned inome*.. Controlled orgniztions inome/interest*..... Investment inome, speifi orgniztions*. Exploited exempt tivity inome*.... Other inome..... Totl trde or usiness inome.... Compenstion of offiers, et.. Other slries nd wges Repirs nd mintenne Bd dets. Interest.... Txes nd lienses Chritle ontriutions. Depreition nd Depletion.... Deferred ompenstion plns.. Employee enefit progrms....

39 Form 990T Tx Return History 0 Nme Employer Identifition Numer Other dedutions. Net operting loss dedution... Speifi dedution Inome fter expense nd dedutions Inome tx (orporte or trust). Other txes Totl txes Generl usiness redit. Other redits..... Net tx fter redits.... Estimted tx pyments Other pyments.. Blne due/overpyment...,000 -,000,000 -,000 * Inome shown net of expenses