Short Form 990-EZ Return of Organization Exempt From Income Tax

Transcription

1 Form B G I J K Short Form 990-EZ Return of Organization Exempt From Income Tax 204 Under section 50(c), 527, or 4947(a)() of the Internal Revenue Code (except private foundations) Do not enter social security numers on this form as it may e made pulic. Department of the Treasury Internal Revenue Service Information aout Form 990-EZ and its instructions is at A For the 204 calendar year, or tax year eginning, 204, and ending, 20 Open to Pulic Inspection D Employer identification numer Numer and street (or P.O. ox, if mail is not delivered to street address) Room/suite E Telephone numer Accounting Method: Cash Accrual Other (specify) H Check if the organization is not Wesite: L Add lines 5, 6c, and 7 to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part II, column (B) elow) are $500,000 or more, file Form 990 instead of Form 990-EZ $ 99,998 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... Contriutions, gifts, grants, and similar amounts received. 39,697 2 Program service revenue including government fees and contracts Memership dues and assessments Investment income a Gross amount from sale of assets other than inventory... 5a Less: cost or other asis and sales expenses 5 c Gain or (loss) from sale of assets other than inventory (Sutract line 5 from line 5a)... 5c 6 Gaming and fundraising events Revenue a Gross income from gaming (attach Schedule G if greater than $5,000).. Gross income from fundraising events (not including $ from fundraising events reported on line ) (attach Schedule G if the sum of such gross income and contriutions exceeds $5,000) 6 60,30 c Less: direct expenses from gaming and fundraising events.. 6c 5,879 d Net income or (loss) from gaming and fundraising events (add lines 6a and 6 and sutract line 6c).. 6d 7a Gross sales of inventory, less returns and allowances... 7a Less: cost of goods sold.. 7 c Gross profit or (loss) from sales of inventory (Sutract line 7 from line 7a). 7c 8 Other revenue (descrie in Schedule O) Total revenue. Add lines, 2, 3, 4, 5c, 6d, 7c, and Grants and similar amounts paid (list in Schedule O)... 0 Benefits paid to or for memers... 2 Salaries, other compensation, and employee enefits Professional fees and other payments to independent contractors Occupancy, rent, utilities, and maintenance 4 5 Printing, pulications, postage, and shipping 5 6 Other expenses (descrie in Schedule O). 6 7 Total expenses. Add lines 0 through Excess or (deficit) for the year (Sutract line 7 from line 9) 8 9 Net assets or fund alances at eginning of year (from line 27, column (A)) (must agree with end-of-year figure reported on prior year's return) Other changes in net assets or fund alances (explain in Schedule O) Net assets or fund alances at end of year. Comine lines 8 through 20 2 For Paperwork Reduction Act Notice, see the separate instructions. Expenses Net Assets Check if applicale: Address change Name change Initial return Final return/terminated Amended return Application pending Tax-exempt status (check only one) - C Name of organization 45 Boylston Street (40) City or town, state or province, country, and ZIP or foreign postal code Warwick, RI (c)(3) 50(c)( ) (insert no.) 4947(a)() or 527 Form of organization: Corporation Trust Association Other 6a of contriutions F Group Exemption Numer required to attach Schedule B (Form 990, 990-EZ, or 990-PF). OMB No ,422 84,9 6,055 67,587 73,642 0,477 68,703 (898) 78,282 Form 990-EZ (204)

2 Form 990-EZ (204) Part II Page 2 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 39, , Land and uildings Other assets (descrie in Schedule O)... 28, , Total assets. 68, , Total liailities (descrie in Schedule O) Net assets or fund alances (line 27 of column (B) must agree with line 2). 68, ,282 Part III Statement of Program Service Accomplishments (see the instructions for Part III) Expenses Check if the organization used Schedule O to respond to any question in this Part III... (Required for section What is the organization's primary exempt purpose? TO PROVIDE CARE PACKAGES FOR NICU Descrie the organization's program service accomplishments for each of its three largest program services, as measured y expenses. In a clear and concise manner, descrie the services provided, the numer of persons enefited, and other relevant information for each program title PKGS, 508 ITEMS AND 7 PROGRAM EVENTS WERE DELIVERED TO HOSPITALS AND FAMILIES WITH AN INFANT IN THE ICU AND THOSE WHO HAVE EPERIENCED PREGNANCY AND INFANT LOSS. (Grants $ ) If this amount includes foreign grants, check here 50(c)(3) and 50(c)(4) organizations; optional for for others.) 28a 0 30 (Grants $ ) If this amount includes foreign grants, check here 29a (Grants $ ) If this amount includes foreign grants, check here 30a 3 Other program services (descrie in Schedule O)... (Grants $ ) If this amount includes foreign grants, check here 3a 32 Total program service expenses (add lines 28a through 3a) 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 (c) Reportale (d) Health enefits, () Average compensation contriutions to employee (e) Estimated amount of hours per week (Forms W-2/099-MISC) enefit plans, and other compensation devoted to position (if not paid, enter -0-) deferred compensation SARAH KING PRESIDENT THERESA KING SECRETARY CORIN NAVA TREASURER Form 990-EZ (204)

3 Form 990-EZ (204) Part V Page 3 Other Information (Note the Schedule A and personal enefit 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 copy of the amended documents if they reflect a change to the organization's name. Otherwise, explain the change on Schedule O (see instructions). 35 a Did the organization have unrelated usiness gross income of $,000 or more during the year from usiness activities (such as those reported on lines 2, 6a, and 7a, among others)?.. If "Yes," to line 35a, has the organization filed a Form 990-T for the year? If "No," provide an explanation in Schedule O... c Was the organization a section 50(c)(4), 50(c)(5), or 50(c)(6) organization suject to section 6033(e) notice, reporting, and proxy tax requirements during the year? If "Yes," complete Schedule C, Part III Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If "Yes," complete applicale parts of Schedule N a Enter amount of political expenditures, direct or indirect, as descried in the instructions... 37a Did the organization file Form 20-POL for this year?.. 38 a Did the organization orrow 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 y this return?. If "Yes," complete Schedule L, Part II and enter the total amount involved Section 50(c)(7) organizations. Enter: a Initiation fees and capital contriutions included on line a Gross receipts, included on line 9, for pulic use of clu facilities a Section 50(c)(3) organizations. Enter amount of tax imposed on the organization during the year under: 4 c d e 42 a 43 At any time during the calendar year, did the organization have an interest in or a signature or other authority over Yes No a financial account in a foreign country (such as a ank account, securities account, or other financial account)? If "Yes," enter the name of the foreign country: c 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... Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed section 49 ; section 492 ; section 4955 Section 50(c)(3), 50(c)(4), and 50(c)(29) organizations. Did the organization engage in any section 4958 excess enefit transaction during the year, or did it engage in an excess enefit transaction in a prior year that has not een reported on any of its prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I Section 50(c)(3), 50(c)(4), and 50(c)(29) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 492, 4955, and Section 50(c)(3), 50(c)(4), and 50(c)(29) organizations. Enter amount of tax on line 40c reimursed y the organization... All organizations. At any time during the tax year, was the organization a party to a prohiited tax shelter transaction? If "Yes," complete Form 8886-T List the states with which a copy of this return is filed PA, RI The organization's ooks are in care of CORIN NAVA Telephone no Located at 45 Boylston Street, Warwick, RI ZIP See the instructions for exceptions and filing requirements for FinCEN Form 4, Report of Foreign Bank and. Financial Accounts (FBAR). 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: Section 4947(a)() nonexempt charitale trusts filing Form 990-EZ in lieu of Form 04-Check here.. and enter the amount of tax-exempt interest received or accrued during the tax year 43 Yes 44 a Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must e completed instead of Form 990-EZ... 44a Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must e completed instead of Form 990-EZ 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 52()(3)?... 45a Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 52()(3)? If "Yes," Form 990 and Schedule R may need to e completed instead of Form 990-EZ (see instructions) Form 990-EZ (204) a 35 35c a 40 40e No

4 Form 990-EZ (204) 46 Did the organization engage, directly or indirectly, in political campaign activities on ehalf of or in opposition to candidates for pulic office? If "Yes," complete Schedule C, Part I Part VI Section 50(c)(3) organizations only All section 50(c)(3) organizations must answer questions and 52, and complete the tales for lines 50 and 5. Check if the organization used Schedule O to respond to any question in this Part VI... Yes No 47 Did the organization engage in loying activities or have a section 50(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II Is the organization a school as descried in section 70()()(A)(ii)? If "Yes," complete Schedule E a Did the organization make any transfers to an exempt non-charitale related organization?. 49a If "Yes," was the related organization a section 527 organization? Complete this tale for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $00,000 of compensation from the organization. If there is none, enter "None." (c) (d) Health enefits, () Average Reportale contriutions to employee (e) Estimated amount of (a) Name and title of each employee hours per week compensation enefit plans, and deferred other compensation devoted to position (Forms W-2/099-MISC) compensation Yes Page 4 No NONE 5 f Total numer of other employees paid over $00, Complete this tale for the organization's five highest compensated independent contractors who each received more than $00,000 of compensation from the organization. If there is none, enter "None." (a) Name and usiness address of each independent contractor () Type of service (c) Compensation NONE 52 d Sign Here Paid Preparer Use Only Total numer of other independent contractors each receiving over $00, Did the organization complete Schedule A? Note. All section 50(c)(3) organizations must attach a completed Schedule A Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the est of my knowledge and elief, it is true, correct, and complete. Declaration of preparer (other than officer) is ased on all information of which preparer has any knowledge. Signature of officer Type or print name and title Print/Type preparer's name Preparer's signature Date Check if PTIN David Brown David Brown self-employed P02547 Firm's name Firm's address May the IRS discuss this return with the preparer shown aove? See instructions CORIN NAVA CORIN NAVA, TREASURER David N Brown CPA 52 Centre Street Date Firm's EIN Rumford RI 0296 Phone no Yes Yes No No Form 990-EZ (204)

5 SCHEDULE A (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Service Name of the organization Pulic Charity Status and Pulic Support Complete if the organization is a section 50(c)(3) organization or a section 4947(a)() nonexempt charitale trust. Attach to Form 990 or Form 990-EZ. Information aout Schedule A (Form 990 or 990-EZ) and its instructions is at Part I Reason for Pulic Charity Status (All organizations must complete this part.) See instructions. The organization is not a private foundation ecause it is: (For lines through, check only one ox.) (A) a c d e f g A church, convention of churches, or association of churches descried in section 70()()(A)(i). A school descried in section 70()()(A)(ii). (Attach Schedule E.) A hospital or a cooperative hospital service organization descried in section 70()()(A)(iii). A medical research organization operated in conjunction with a hospital descried in section 70()()(A)(iii). Enter the hospital's name, city, and state: An organization operated for the enefit of a college or university owned or operated y a governmental unit descried in section 70()()(A)(iv). (Complete Part II.) A federal, state, or local government or governmental unit descried in section 70()()(A)(v). An organization that normally receives a sustantial part of its support from a governmental unit or from the general pulic descried in section 70()()(A)(vi). (Complete Part II.) A community trust descried in section 70()()(A)(vi). (Complete Part II.) An organization that normally receives: () more than 33 /3% of its support from contriutions, memership fees, and gross receipts from activities related to its exempt functions - suject to certain exceptions, and (2) no more than 33 /3% of its support from gross investment income and unrelated usiness taxale income (less section 5 tax) from usinesses acquired y the organization after June 30, 975. See section 509(a)(2). (Complete Part III.) An organization organized and operated exclusively to test for pulic safety. See section 509(a)(4). An organization organized and operated exclusively for the enefit of, to perform the functions of, or to carry out the purposes of one or more pulicly supported organizations descried in section 509(a)() or section 509(a)(2). See section 509(a)(3). Check the ox in lines a through d that descries the type of supporting organization and complete lines e, f, and g. Type I. A supporting organization operated, supervised, or controlled y its supported organization(s), typically y giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B. Type II. A supporting organization supervised or controlled in connection with its supported organization(s), y having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C. Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E. Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distriution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V. Check this ox if the organization received a written determination from the IRS that it is a Type I, Type II, Type III Employer identification numer functionally integrated, or Type III non-functionally integrated supporting organization. Enter the numer of supported organizations. Provide the following information aout the supported organization(s). OMB No Open to Pulic Inspection (i) Name of supported organization (ii) EIN (iii) Type of organization (iv) Is the organization (v) Amount of monetary (vi) Amount of (descried on lines -9 listed in your governing support (see other support (see aove or IRC section document? instructions) instructions) (see instructions)) Yes No (B) (C) (D) (E) Total For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule A (Form 990 or 990-EZ) 204

6 Schedule A (Form 990 or 990-EZ) 204 Page 2 Part II Support Schedule for Organizations Descried in Sections 70()()(A)(iv) and 70()()(A)(vi) (Complete only if you checked the ox on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed elow, please complete Part III.) Section A. Pulic Support Calendar year (or fiscal year eginning in) (a) 200 () 20 (c) 202 (d) 203 (e) 204 (f) Total 2 Gifts, grants, contriutions, and memership fees received. (Do not include any "unusual grants.")... Tax revenues levied for the organization's enefit and either paid to or expended on its ehalf The value of services or facilities furnished y a governmental unit to the organization without charge... Total. Add lines through 3... The portion of total contriutions y each person (other than a governmental unit or pulicly supported organization) included on line that exceeds 2% of the amount shown on line, column (f)... 6 Pulic support. Sutract line 5 from line 4.. Section B. Total Support Calendar year (or fiscal year eginning in) 7 Amounts from line Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources (a) 200 () 20 (c) 202 (d) 203 (e) 204 (f) Total 9 Net income from unrelated usiness activities, whether or not the usiness is regularly carried on. 0 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)... Total support. Add lines 7 through 0. 2 Gross receipts from related activities, etc. (see instructions) First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 50(c)(3) organization, check this ox and stop here. Section C. Computation of Pulic Support Percentage 4 Pulic support percentage for 204 (line 6, column (f) divided y line, column (f))... 4 % 5 Pulic support percentage from 203 Schedule A, Part II, line 4 5 % 6a 33 /3% support test If the organization did not check the ox on line 3, and line 4 is 33 /3% or more, check this ox and stop here. The organization qualifies as a pulicly supported organization /3% support test If the organization did not check a ox on line 3 or 6a, and line 5 is 33 /3% or more, check this ox and stop here. The organization qualifies as a pulicly supported organization... 7a 0%-facts-and-circumstances test If the organization did not check a ox on line 3, 6a, or 6, and line 4 is 0% or more, and if the organization meets the "facts-and-circumstances" test, check this ox and stop here. Explain in 8 Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a pulicly supported organization... 0%-facts-and-circumstances test If the organization did not check a ox on line 3, 6a, 6, or 7a, and line 5 is 0% or more, and if the organization meets the "facts-and-circumstances" test, check this ox and stop here. Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a pulicly supported organization. Private foundation. If the organization did not check a ox on line 3, 6a, 6, 7a, or 7, check this ox and see instructions... Schedule A (Form 990 or 990-EZ) 204

7 Schedule A (Form 990 or 990-EZ) 204 Page 3 Part III Support Schedule for Organizations Descried in Section 509(a)(2) (Complete only if you checked the ox on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed elow, please complete Part II.) Section A. Pulic Support Calendar year (or fiscal year eginning in) (a) 200 () 20 (c) 202 (d) 203 (e) 204 (f) Total a Gifts, grants, contriutions, and memership fees received. (Do not include any "unusual grants.") Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose Gross receipts from activities that are not an unrelated trade or us. under sec 53 Tax revenues levied for the organization's enefit and either paid to or expended on its ehalf The value of services or facilities furnished y a governmental unit to the organization without charge Total. Add lines through 5 Amounts included on lines, 2, and 3 received from disqualified persons ,6 32,858 28,563 65,49 39, ,48 36,390 42,334 48,3 60,30 87,336 40,6 69,248 70,897 3,730 99, ,484 c Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or % of the amount on line 3 for the year Add lines 7a and Pulic support (Sutract line 7c from line 6.). Section B. Total Support Calendar year (or fiscal year eginning in) 9 Amounts from line 6... (a) 200 () 20 (c) 202 (d) 203 (e) 204 (f) Total 394,484 40,6 69,248 70,897 3,730 99, ,484 0a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. c Unrelated usiness taxale income (less section 5 taxes) from usinesses acquired after June 30, 975 Add lines 0a and 0... Net income from unrelated usiness activities not included in line 0, whether or not the usiness is regularly carried on... 2 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)... 3 Total support. (Add lines 9, 0c,, and 2.). 40,6 69,248 70,897 3,730 99, ,484 4 First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 50(c)(3) organization, check this ox and stop here. Section C. Computation of Pulic Support Percentage 5 Pulic support percentage for 204 (line 8, column (f) divided y line 3, column (f)) % 6 Pulic support percentage from 203 Schedule A, Part III, line 5 6 % Section D. Computation of Investment Income Percentage 7 Investment income percentage for 204 (line 0c, column (f) divided y line 3, column (f)) % 8 Investment income percentage from 203 Schedule A, Part III, line % 9a 33 /3% support tests If the organization did not check the ox on line 4, and line 5 is more than 33 /3%, and line 7 is not more than 33 /3%, check this ox and stop here. The organization qualifies as a pulicly supported organization.. 33 /3% support tests If the organization did not check a ox on line 4 or line 9a, and line 6 is more than 33 /3%, and line 8 is not more than 33 /3%, check this ox and stop here. The organization qualifies as a pulicly supported organization 20 Private foundation. If the organization did not check a ox on line 4, 9a, or 9, check this ox and see instructions... Schedule A (Form 990 or 990-EZ) 204

8 SCHEDULE G (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Service Name of the organization Supplemental Information Regarding Fundraising or Gaming Activities Complete if the organization answered "Yes" to Form 990, Part IV, lines 7, 8, or 9, or if the organization entered more than $5,000 on Form 990-EZ, line 6a. Attach to Form 990 or Form 990-EZ. Information aout Schedule G (Form 990 or 990-EZ) and its instructions is at Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 7. Part I Form 990-EZ filers are not required to complete this part. a c d 2a Indicate whether the organization raised funds through any of the following activities. Check all that apply. Mail solicitations Internet and solicitations Phone solicitations In-person solicitations e f g Solicitation of non-government grants Solicitation of government grants Special fundraising events Did the organization have a written or oral agreement with any individual (including officers, directors, trustees or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services? If "Yes," list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is to e compensated at least $5,000 y the organization. Yes OMB No Open to Pulic Inspection Employer identification numer No (v) Amount paid to (iii) Did fundraiser have (i) Name and address of individual (iv) Gross receipts (or retained y) (ii) Activity custody or control of or entity (fundraiser) from activity fundraiser listed in contriutions? col. (i) Yes No (vi) Amount paid to (or retained y) organization Total... 3 List all states in which the organization is registered or licensed to solicit contriutions or has een notified it is exempt from registration or licensing. Florida, California, Massachusettes, Ohio, Illinois, Connecticut, Tennessee, Minnesota Wisconsin, Rhode Island, Oklahoma, Pennsylvania For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule G (Form 990 or 990-EZ) 204

9 Part II Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 8, or reported more than $5,000 of fundraising event contriutions and gross income on Form 990-EZ, lines and 6. List events with gross receipts greater than $5,000. Schedule G (Form 990 or 990-EZ) 204 (a) Event # () Event #2 (c) Other events (d) Total events Polar Plunge Walks (add col. (a) through col. (c)) (event type) (event type) (total numer) Page 2 Revenue Gross receipts. 36,79 0,888 2,622 60, Less: Contriutions... Gross income (line minus line 2)... 36,79 0,888 2,622 60,30 4 Cash prizes.. 5 Noncash prizes Direct Expenses Rent/facility costs Food and everages... Entertainment. 9 Other direct expenses... 9,707 3,269 2,903 5,879 0 Direct expense summary. Add lines 4 through 9 in column (d)... Net income summary. Sutract line 0 from line 3, column (d)... Part III Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 9, or reported more than $5,000 on Form 990-EZ, line 6a. Revenue Gross revenue. (a) Bingo () Pull tas/instant ingo/progressive ingo (c) Other gaming 5,879 44,422 (d) Total gaming (add col. (a) through col. (c)) Direct Expenses Cash prizes.. Noncash prizes Rent/facility costs... 5 Other direct expenses... Yes % Yes % Yes % 6 Volunteer laor No No No 7 Direct expense summary. Add lines 2 through 5 in column (d)... 8 Net gaming income summary. Sutract line 7 from line, column (d)... 9 Enter the state(s) in which the organization conducts gaming activities: a Is the organization licensed to conduct gaming activities in each of these states?... Yes No If "No," explain: 0a Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year?.. Yes No If "Yes," explain: Schedule G (Form 990 or 990-EZ) 204

10 SCHEDULE O (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Service Name of the organization Supplemental Information to Form 990 or 990-EZ Complete to provide information for responses to specific questions on Form 990 or 990-EZ or to provide any additional information. Attach to Form 990 or 990-EZ. Information aout Schedule O (Form 990 or 990-EZ) and its instructions is at 0. Description of other expenses (Part I, line 6) OMB No Open to Pulic Inspection Employer identification numer Description Amount Gift ag items and program expenses 6,846 Bank Fees 565 Information technology/wesite Host 657 Volunteer Events 406 Insurance 2,899 State registration and fees 758 Advetising and promotional Other changes in net assets or fund alances (Part I, line 20) Description Amount Inventory (898) 03. Description of other assets (Part II, line 24) Category Beginning of Year End of Year INVENTORY 28,767 34,530 For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule O (Form 990 or 990-EZ) (204)

11 Form 8879-EO Department of the Treasury Internal Revenue Service Name of exempt organization IRS e-file Signature Authorization for an Exempt Organization For calendar year 204, or fiscal year eginning, and ending CORIN NAVA, TREASURER Part I Type of Return and Return Information (Whole Dollars Only) Check the ox for the return for which you are using this Form 8879-EO and enter the applicale amount, if any, from the return. If you check the ox on line a, 2a, 3a, 4a, or 5a, elow, and the amount on that line for the return eing filed with this form was lank, then leave line, 2, 3, 4, or 5, whichever is applicale, lank (do not enter -0-). But, if you entered -0- on the return, then enter -0- on the applicale line elow. Do not complete more than line in Part I. Part II Declaration and Signature Authorization of Officer Under penalties of perjury, I declare that I am an officer of the aove organization and that I have examined a copy of the organization's 204 electronic return and accompanying schedules and statements and to the est of my knowledge and elief, they are true, correct, and complete. I further declare that the amount in Part I aove is the amount shown on the copy of the organization's electronic return. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO) to send the organization's return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, () the reason for any delay in processing the return or refund, and (c) the date of any refund. If applicale, I authorize the U.S. Treasury and its designated Financial Agent to initiate an electronic funds withdrawal (direct deit) entry to the financial institution account indicated in the tax preparation software for payment of the organization's federal taxes owed on this return, and the financial institution to deit the entry to this account. To revoke a payment, I must contact the U.S. Treasury Financial Agent at no later than 2 usiness days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I have selected a personal identification numer (PIN) as my signature for the organization's electronic return and, if applicale, the organization's consent to electronic funds withdrawal. Officer's PIN: check one ox only Part III Do not send to the IRS. Keep for your records. Information aout Form 8879-EO and its instructions is at Certification and Authentication 204 a Form 990 check here Total revenue, if any (Form 990, Part VIII, column (A), line 2)... 2a Form 990-EZ check here Total revenue, if any (Form 990-EZ, line 9) ,9 3a Form 20-POL check here Total tax (Form 20-POL, line 22) a Form 990-PF check here Tax ased on investment income (Form 990-PF, Part VI, line 5) a Form 8868 check here Balance Due (Form 8868, Part I, line 3c or Part II, line 8c)... 5 I authorize to enter my PIN as my signature ERO firm name Enter five numers, ut do not enter all zeros on the organization's tax year 204 electronically filed return. If I have indicated within this return that a copy of the return is eing filed with a state agency(ies) regulating charities as part of the IRS Fed/State program, I also authorize the aforementioned ERO to enter my PIN on the return's disclosure consent screen. As an officer of the organization, I will enter my PIN as my signature on the organization's tax year 204 electronically filed return. If I have indicated within this return that a copy of the return is eing filed with a state agency(ies) regulating charities as part of the IRS Fed/State program, I will enter my PIN on the return's disclosure consent screen. 365 ERO's EFIN/PIN. Enter your six-digit electronic filing identification numer (EFIN) followed y your five-digit self-selected PIN. Employer identification numer Name and title of officer Officer's signature Date do not enter all zeros OMB No I certify that the aove numeric entry is my PIN, which is my signature on the 204 electronically filed return for the organization indicated aove. I confirm that I am sumitting this return in accordance with the requirements of Pu. 463, Modernized e-file (MeF) Information for Authorized IRS e-file Providers for Business Returns. ERO's signature David Brown Date ERO Must Retain This Form - See Instructions Do Not Sumit This Form To the IRS Unless Requested To Do So For Paperwork Reduction Act Notice, see instructions. Form 8879-EO (204)

12 990 Overflow Statement 204 Page Name(s) as shown on return FEIN PROJECT SWEET PEAS Contriutions, Grants Description Amount Financial Review Summary $ 33,268 In Kind 6,429 Total: $ 39,697 FUNDRAISING Description Amount EVENTS $ 60,069 IN KIND 232 Total: $ 60,30 Printing, Postage Description Amount Postage $ 4,002 Printing/Office 2,053 Total: $ 6,055 OVERFLOW.LD

13 FOR TA YEAR 204 PROJECT SWEET PEAS David N Brown CPA 52 Centre Street Rumford, RI 0296 (40)