2015 Exempt Org. Return prepared for: Katie's House, Inc. c/o Evelyn Dudziec 29 Moran Street Newton, NJ 07860

Transcription

1 0 Exempt Org. Return prepared for: Katie's House, Inc. c/o Evelyn Dudziec 9 Moran Street Newton, NJ 00 Cullari Carrico, LLC Lane Road Ste. 00 Fairfield, NJ 000

2 CLIENT KATIE CULLARI CARRICO, LLC LANE ROAD STE. 00 FAIRFIELD, NJ August 0, 0 Katie's House, Inc. c/o Evelyn Dudziec 9 Moran Street Newton, NJ 00 Dear Evelyn: Enclosed for your review: Form Return of Organization Exempt from Income Tax Each tax return or form listed above should be filed in accordance with the enclosed filing instructions. Please be sure to call us if you have any questions. Sincerely, JOHN CARRICO JR.

3 CULLARI CARRICO, LLC Client KATIE August 0, 0 LANE ROAD STE. 00 FAIRFIELD, NJ Katie's House, Inc. c/o Evelyn Dudziec 9 Moran Street Newton, NJ FEDERAL FORMS Form 990 Schedule A Schedule B Schedule D Schedule Schedule O Form Form 9-EO 0 Return of Organization Exempt from Income Tax Organization Exempt Under Section 0(c)() Schedule of Contributors Schedule D Fundraising or aming Activities Supplemental Information Application for Extension Depreciation Schedules IRS e-file Signature Authorization FEE SUMMARY Preparation Fee

4 0 FEDERAL FILIN INSTRUCTIONS CLIENT KATIE C/O EVELYN DUDZIEC /0/ -999 :AM ELECTRONICALLY FILED: FORM RETURN OF ORANIZATION EEMPT FROM INCOME TA THE ABOVE TA RETURN WILL BE ELECTRONICALLY FILED WITH THE INTERNAL REVENUE SERVICE UPON RECEIPT OF A SINED FORM 9-EO - IRS E-FILE SINATURE AUTHORIZATION. PAYMENT: NO PAYMENT IS REQUIRED.

5 Form 9-EO Department of the Treasury Internal Revenue Service Name of exempt organization Name and title of officer IRS e-file Signature Authorization for an Exempt Organization For calendar year 0, or fiscal year beginning, 0, and ending OMB. -, 0 0 Do not send to the IRS. Keep for your records. Information about Form 9-EO and its instructions is at Employer identification number C/O EVELYN DUDZIEC -999 CHARLES CASEY TREASURER Part I Type of Return and Return Information (Whole Dollars Only) Check the box for the return for which you are using this Form 9-EO and enter the applicable amount, if any, from the return. If you check the box on line a, a, a, a, or a, below, and the amount on that line for the return being filed with this form was blank, then leave line b, b, b, b, or b, whichever is applicable, blank (do not enter -0-). But, if you entered -0- on the return, then enter -0- on the applicable line below. Do not complete more than line in Part I. a a a a a Form 990 check here..... b Total revenue, if any (Form 990, Part VIII, column (A), line ) Form 990-EZ check here..... b Total revenue, if any (Form 990-EZ, line 9) Form 0-POL check here b Total tax (Form 0-POL, line ) Form 990-PF check here..... b Tax based on investment income (Form 990-PF, Part VI, line ).... Form check here.... b Balance Due (Form, Part I, line c or Part II, line c) ,. b b b b b Part II Declaration and Signature Authorization of Officer Under penalties of perjury, I declare that I am an officer of the above organization and that I have examined a copy of the organization's 0 electronic return and accompanying schedules and statements and to the best of my knowledge and belief, they are true, correct, and complete. I further declare that the amount in Part I above 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, (b) the reason for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial Agent to initiate an electronic funds withdrawal (direct debit) 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 debit the entry to this account. To revoke a payment, I must contact the U.S. Treasury Financial Agent at --- no later than business 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 number (PIN) as my signature for the organization's electronic return and, if applicable, the organization's consent to electronic funds withdrawal. Officer's PIN: check one box only I authorize CULLARI CARRICO, LLC to enter my PIN ERO firm name 09 as my signature Enter five numbers, but do not enter all zeros on the organization's tax year 0 electronically filed return. If I have indicated within this return that a copy of the return is being 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 0 electronically filed return. If I have indicated within this return that a copy of the return is being 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. Officer's signature Date Part III Certification and Authentication ERO's EFIN/PIN. Enter your six-digit electronic filing identification number (EFIN) followed by your five-digit self-selected PIN do not enter all zeros I certify that the above numeric entry is my PIN, which is my signature on the 0 electronically filed return for the organization indicated above. I confirm that I am submitting this return in accordance with the requirements of Pub., Modernized e-file (MeF) Information for Authorized IRS e-file Providers for Business Returns. ERO's signature Date ERO Must Retain This Form ' See Instructions Do t Submit This Form To the IRS Unless Requested To Do So For Paperwork Reduction Act tice, see instructions. Form 9-EO (0) TEEA0L 0//

6 Form Application for Extension of Time To File an Exempt Organization Return (Rev January 0) OMB. -09 File a separate application for each return. Department of the Treasury Internal Revenue Service Information about Form and its instructions is at If you are filing for an Automatic -Month Extension, complete only Part I and check this box ? If you are filing for an Additional (t Automatic) -Month Extension, complete only Part II (on page of this form). Do not complete Part II unless you have already been granted an automatic -month extension on a previously filed Form. Electronic filing (e-file). You can electronically file Form if you need a -month automatic extension of time to file ( months for a corporation required to file Form 990-T), or an additional (not automatic) -month extension of time. You can electronically file Form to request an extension of time to file any of the forms listed in Part I or Part II with the exception of Form 0, Information Return for Transfers Associated With Certain Personal Benefit Contracts, which must be sent to the IRS in paper format (see instructions). For more details on the electronic filing of this form, visit and click on e-file for Charities & nprofits. Part I Automatic -Month Extension of Time. Only submit original (no copies needed). A corporation required to file Form 990-T and requesting an automatic -month extension ' check this box and complete Part I only..... All other corporations (including 0-C filers), partnerships, REMICs, and trusts must use Form 00 to request an extension of time to file income tax returns. Enter filer's identifying number, see instructions Type or print Name of exempt organization or other filer, see instructions. Employer identification number (EIN) or C/O EVELYN DUDZIEC -999 Number, street, and room or suite number. If a P.O. box, see instructions. File by the due date for filing your return. See instructions. Social security number (SSN) 9 MORAN STREET City, town or post office, state, and ZIP code. For a foreign address, see instructions. NEWTON, NJ 00 Enter the Return code for the return that this application is for (file a separate application for each return) Application Is For Return Code Return Code Application Is For Form 990 or Form 990-EZ 0 Form 990-T (corporation) 0 Form 990-BL Form 0 (individual) Form 990-PF Form 0-A Form 0 (other than individual) Form Form 990-T (section 0(a) or 0(a) trust) Form 990-T (trust other than above) 0 0 Form 09 Form 0? The books are in the care of CHARLES CASEY Fax. 9-- If the organization does not have an office or place of business in the United States, check this box If this is for a roup Return, enter the organization's four digit roup Exemption Number (EN). If this is for the whole group, check this box If it is for part of the group, check this box.... and attach a list with the names and EINs of all members Telephone.?? the extension is for. I request an automatic -month ( months for a corporation required to file Form 990-T) extension of time until, 0, to file the exempt organization return for the organization named above. / The extension is for the organization's return for: calendar year 0 or tax year beginning, 0, and ending If the tax year entered in line is for less than months, check reason: Change in accounting period, 0 Initial return. Final return a If this application is for Forms 990-BL, 990-PF, 990-T, 0, or 09, enter the tentative tax, less any nonrefundable credits. See instructions b If this application is for Forms 990-PF, 990-T, 0, or 09, enter any refundable credits and estimated tax payments made. Include any prior year overpayment allowed as a credit b c Balance due. Subtract line b from line a. Include your payment with this form, if required, by using EFTPS (Electronic Federal Tax Payment System). See instructions c a Caution. If you are going to make an electronic funds withdrawal (direct debit) with this Form, see Form -EO and Form 9-EO for payment instructions. For Privacy Act and Paperwork Reduction Act tice, see instructions. FIFZ00L // Form (Rev -0)

7 Form (Rev -0) Page? If you are filing for an Additional (t Automatic) -Month Extension, complete only Part II and check this box te. Only complete Part II if you have already been granted an automatic -month extension on a previously filed Form.? If you are filing for an Automatic -Month Extension, complete only Part I (on page ). Additional (t Automatic) -Month Extension of Time. Only file the original (no copies needed). Part II Enter filer's identifying number, see instructions Type or print Name of exempt organization or other filer, see instructions. Employer identification number (EIN) or C/O EVELYN DUDZIEC -999 Social security number (SSN) Number, street, and room or suite number. If a P.O. box, see instructions. File by the due date for filing your return. See instructions. CULLARI CARRICO, LLC LANE ROAD STE. 00 City, town or post office, state, and ZIP code. For a foreign address, see instructions. FAIRFIELD, NJ 000 Enter the Return code for the return that this application is for (file a separate application for each return) Application Is For Return Code Return Code Form 990 or Form 990-EZ Form 990-BL Form 0 (individual) Form 990-PF Form 990-T (section 0(a) or 0(a) trust) Form 990-T (trust other than above) Application Is For Form 0-A Form 0 (other than individual) Form Form 09 Form STOP! Do not complete Part II if you were not already granted an automatic -month extension on a previously filed Form.? The books are in the care of CHARLES CASEY Telephone. 9-- Fax.? If the organization does not have an office or place of business in the United States, check this box ? If this is for a roup Return, enter the organization's four digit roup Exemption Number (EN).... If this is for the whole group, check this box..... If it is for part of the group, check this box and attach a list with the names and EINs of all members the extension is for. I request an additional -month extension of time until / For calendar year 0, or other tax year beginning If the tax year entered in line is for less than months, check reason: Change in accounting period State in detail why you need the extension.. ADDITIONAL TIME, 0., 0, and ending Initial return, 0. Final return IS REQUIRED IN ORDER TO OBTAIN THIRD PARTY INFORMATION NECESSARY FOR THE FILIN OF A COMPLETE AND ACCURATE TA RETURN a If this application is for Forms 990-BL, 990-PF, 990-T, 0, or 09, enter the tentative tax, less any nonrefundable credits. See instructions a b If this application is for Forms 990-PF, 990-T, 0, or 09, enter any refundable credits and estimated tax payments made. Include any prior year overpayment allowed as a credit and any amount paid previously with Form b c Balance due. Subtract line b from line a. Include your payment with this form, if required, by using EFTPS (Electronic Federal Tax Payment System). See instructions c Signature and Verification must be completed for Part II only. Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete, and that I am authorized to prepare this form. Signature Title TREASURER Date Form (Rev -0) FIFZ00L //

8 Form 990 OMB. -00 Department of the Treasury Internal Revenue Service A B For the 0 calendar year, or tax year beginning C Check if applicable: Address change Name change Initial return Final return/terminated 0 Return of Organization Exempt From Income Tax Under section 0(c),, or 9(a)() of the Internal Revenue Code (except private foundations) Do not enter social security numbers on this form as it may be made public. Information about Form 990 and its instructions is at Open to Public Inspection, 0, and ending, C/O EVELYN DUDZIEC 9 MORAN STREET NEWTON, NJ 00 D Employer identification number E Telephone number ,. EVELYN DUDZIEC H(b) Are all subordinates included? WITT LANE NEWTON, NJ 00 If ',' attach a list. (see instructions) )H (insert no.) Tax-exempt status 0(c) ( 9(a)() or I 0(c)() J Website: N/A H(c) roup exemption number Form of organization: Trust Association Other K Corporation L Year of formation: M State of legal domicile: NJ Part I Summary Briefly describe the organization's mission or most significant activities: TO PROVIDE SECURE, INDEPENDENT ASSISTED LIVIN HOMES WITH HOUSE PARENTS TO OVERSEE THE DAILY NEEDS OF SPECIAL NEEDS ADULTS, IE:ADULTS WHOSE DEVELOPMENTAL OR PHYSICAL DISABILITIES PREVENT THEM FROM LIVIN INDEPENDENTLY WITHOUT SUPERVISION. Amended return Application pending a b 9 0 F ross receipts H(a) Is this a group return for subordinates? Name and address of principal officer: Check this box if the organization discontinued its operations or disposed of more than % of its net assets. Number of voting members of the governing body (Part VI, line a) Number of independent voting members of the governing body (Part VI, line b) Total number of individuals employed in calendar year 0 (Part V, line a) Total number of volunteers (estimate if necessary) Total unrelated business revenue from Part VIII, column (C), line a Net unrelated business taxable income from Form 990-T, line b Prior Year Current Year Contributions and grants (Part VIII, line h) ,. 9,. Program service revenue (Part VIII, line g) ,., Investment income (Part VIII, column (A), lines,, and d) Other revenue (Part VIII, column (A), lines, d, c, 9c, 0c, and e) ,.,. Total revenue ' add lines through (must equal Part VIII, column (A), line ).....,.,. rants and similar amounts paid (Part I, column (A), lines -) Benefits paid to or for members (Part I, column (A), line ) Salaries, other compensation, employee benefits (Part I, column (A), lines -0).....,., 9,. 09,0.,9. 0,0.,.,. a Professional fundraising fees (Part I, column (A), line e) b Total fundraising expenses (Part I, column (D), line ) 9 Other expenses (Part I, column (A), lines a-d, f-e) Total expenses. Add lines - (must equal Part I, column (A), line ) Revenue less expenses. Subtract line from line Total assets (Part, line ) Total liabilities (Part, line ) Net assets or fund balances. Subtract line from line Beginning of Current Year Part II End of Year,9., 0,.,99. 0,.,. Signature Block Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge. Sign Here A A Signature of officer Date CHARLES CASEY TREASURER Type or print name and title. Print/Type preparer's name Preparer's signature JOHN CARRICO JR. Paid Preparer Firm's name CULLARI CARRICO, LLC Use Only Firm's address LANE ROAD STE. 00 FAIRFIELD, NJ 000 Date Check /0/ self-employed if PTIN P May the IRS discuss this return with the preparer shown above? (see instructions) For Paperwork Reduction Act tice, see the separate instructions. Firm's EIN Phone no. TEEA0L 0// Form 990 (0)

9 Statement of Program Service Accomplishments -999 Form 990 (0) Part III Page Check if Schedule O contains a response or note to any line in this Part III Briefly describe the organization's mission: TO PROVIDE SECURE, INDEPENDENT ASSISTED LIVIN HOMES WITH HOUSE PARENTS TO OVERSEE THE DAILY NEEDS OF SPECIAL NEEDS ADULTS, IE:ADULTS WHOSE DEVELOPMENTAL OR PHYSICAL DISABILITIES PREVENT THEM FROM LIVIN INDEPENDENTLY WITHOUT SUPERVISION. Did the organization undertake any significant program services during the year which were not listed on the prior Form 990 or 990-EZ? If ',' describe these new services on Schedule O. Did the organization cease conducting, or make significant changes in how it conducts, any program services?.... If ',' describe these changes on Schedule O. Describe the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 0(c)() and 0(c)() organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported. ) (Revenue,. including grants of OPERATIN AND ACTIVITY EPENSES TO OPERATE THE ST RESIDENCE ON 9 MORAN STREET IN NEWTON, NJ. a (Code: ) (Expenses ) ) (Expenses ) (Revenue ),99. including grants of CENTER FOR ADVANCEMENT EDUCATIONAL/REHABILITAION CLASSES AND ROUP SOCIAL ACTIVITIES FOR PERSONS WITH PHYSICAL AND DEVELOPMENTAL DISABILITIES b (Code: ) (Revenue,. including grants of OPERATIN AND ACTIVITY EPENSES TO OPERATE RESIDENCE ON MASON AVE, NEWTON, NJ c (Code: ) (Expenses d Other program services. (Describe in Schedule O.) (Expenses including grants of e Total program service expenses 0,. TEEA00L ) (Revenue 0// ) ) Form 990 (0)

10 Checklist of Required Schedules -999 Form 990 (0) Part IV Page Is the organization described in section 0(c)() or 9(a)() (other than a private foundation)? If ',' complete Schedule A Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If ',' complete Schedule C, Part I Section 0(c)() organizations. Did the organization engage in lobbying activities, or have a section 0(h) election in effect during the tax year? If ',' complete Schedule C, Part II Is the organization a section 0(c)(), 0(c)(), or 0(c)() organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 9-9? If ',' complete Schedule C, Part III Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If ',' complete Schedule D, Part I Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas, or historic structures? If ',' complete Schedule D, Part II Did the organization maintain collections of works of art, historical treasures, or other similar assets? If ',' complete Schedule D, Part III Did the organization report an amount in Part, line, for escrow or custodial account liability; serve as a custodian for amounts not listed in Part ; or provide credit counseling, debt management, credit repair, or debt negotiation services? If ',' complete Schedule D, Part IV Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If ',' complete Schedule D, Part V If the organization's answer to any of the following questions is '', then complete Schedule D, Parts VI, VII, VIII, I, or as applicable. a Did the organization report an amount for land, buildings and equipment in Part, line 0? If ',' complete Schedule D, Part VI a b Did the organization report an amount for investments ' other securities in Part, line that is % or more of its total assets reported in Part, line? If ',' complete Schedule D, Part VII b c Did the organization report an amount for investments ' program related in Part, line that is % or more of its total assets reported in Part, line? If ',' complete Schedule D, Part VIII c d Did the organization report an amount for other assets in Part, line that is % or more of its total assets reported in Part, line? If ',' complete Schedule D, Part I d e Did the organization report an amount for other liabilities in Part, line? If ',' complete Schedule D, Part e f Did the organization's separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liability for uncertain tax positions under FIN (ASC 0)? If ',' complete Schedule D, Part.... f a Did the organization obtain separate, independent audited financial statements for the tax year? If ',' complete Schedule D, Parts I, and II a b Was the organization included in consolidated, independent audited financial statements for the tax year? If ',' and if the organization answered '' to line a, then completing Schedule D, Parts I and II is optional b a Did the organization maintain an office, employees, or agents outside of the United States? a b Did the organization have aggregate revenues or expenses of more than 0,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at 00,000 or more? If ',' complete Schedule F, Parts I and IV b Did the organization report on Part I, column (A), line, more than,000 of grants or other assistance to or for any foreign organization? If ',' complete Schedule F, Parts II and IV Did the organization report on Part I, column (A), line, more than,000 of aggregate grants or other assistance to or for foreign individuals? If ',' complete Schedule F, Parts III and IV Did the organization report a total of more than,000 of expenses for professional fundraising services on Part I, column (A), lines and e? If ',' complete Schedule, Part I (see instructions) Did the organization report more than,000 total of fundraising event gross income and contributions on Part VIII, lines c and a? If ',' complete Schedule, Part II Did the organization report more than,000 of gross income from gaming activities on Part VIII, line 9a? If ',' complete Schedule, Part III Is the organization a school described in section 0(b)()(A)(ii)? If ',' complete Schedule E TEEA00L 0// Form 990 (0)

11 Checklist of Required Schedules (continued) -999 Form 990 (0) Part IV Page 0a Did the organization operate one or more hospital facilities? If '', complete Schedule H a b If '' to line 0a, did the organization attach a copy of its audited financial statements to this return? b Did the organization report more than,000 of grants or other assistance to any domestic organization or domestic government on Part I, column (A), line? If ',' complete Schedule I, Parts I and II Did the organization report more than,000 of grants or other assistance to or for domestic individuals on Part I, column (A), line? If ',' complete Schedule I, Parts I and III Did the organization answer '' to Part VII, Section A, line,, or about compensation of the organization's current and former officers, directors, trustees, key employees, and highest compensated employees? If ',' complete Schedule J a Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than 00,000 as of the last day of the year, that was issued after December, 00? If ',' answer lines b through d and complete Schedule K. If ', 'go to line a b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? a b c Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? d Did the organization act as an 'on behalf of' issuer for bonds outstanding at any time during the year? c d a Section 0(c)(), 0(c)(), and 0(c)(9) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If ',' complete Schedule L, Part I a b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ? If ',' complete Schedule L, Part I b Did the organization report any amount on Part, line,, or for receivables from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If '', complete Schedule L, Part II Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a % controlled entity or family member of any of these persons? If ',' complete Schedule L, Part III a A current or former officer, director, trustee, or key employee? If ',' complete Schedule L, Part IV a b A family member of a current or former officer, director, trustee, or key employee? If ',' complete Schedule L, Part IV b c An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If ',' complete Schedule L, Part IV Did the organization receive more than,000 in non-cash contributions? If ',' complete Schedule M c 9 Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If ',' complete Schedule M Did the organization liquidate, terminate, or dissolve and cease operations? If ',' complete Schedule N, Part I Did the organization sell, exchange, dispose of, or transfer more than % of its net assets? If ',' complete Schedule N, Part II Did the organization own 00% of an entity disregarded as separate from the organization under Regulations sections 0.0- and 0.0-? If ',' complete Schedule R, Part I Was the organization related to any tax-exempt or taxable entity? If ',' complete Schedule R, Part II, III, or IV, and Part V, line a Did the organization have a controlled entity within the meaning of section (b)()? a b If '' to line a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section (b)()? If ',' complete Schedule R, Part V, line b Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions): 0 Section 0(c)() organizations. Did the organization make any transfers to an exempt non-charitable related organization? If ',' complete Schedule R, Part V, line Did the organization conduct more than % of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If ',' complete Schedule R, Part VI Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines b and 9? te. All Form 990 filers are required to complete Schedule O TEEA00L 0// Form 990 (0)

12 Part V Statements Regarding Other IRS Filings and Tax Compliance -999 Form 990 (0) Page Check if Schedule O contains a response or note to any line in this Part V a Enter the number reported in Box of Form 09. Enter -0- if not applicable b Enter the number of Forms W- included in line a. Enter -0- if not applicable a b 0 c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? c a Enter the number of employees reported on Form W-, Transmittal of Wage and Tax Statements, filed for the calendar year ending with or within the year covered by this return..... a b If at least one is reported on line a, did the organization file all required federal employment tax returns? b te. If the sum of lines a and a is greater than 0, you may be required to e-file (see instructions) a Did the organization have unrelated business gross income of,000 or more during the year? b If '' has it filed a Form 990-T for this year? If '' to line b, provide an explanation in Schedule O a b a a b c a Does the organization have annual gross receipts that are normally greater than 00,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? a b If ',' did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? b a At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? b If ',' enter the name of the foreign country: See instructions for filing requirements for FinCEN Form, Report of Foreign Bank and Financial Accounts. (FBAR) a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? c If ',' to line a or b, did the organization file Form -T? Organizations that may receive deductible contributions under section 0(c). a Did the organization receive a payment in excess of made partly as a contribution and partly for goods and services provided to the payor? b If ',' did the organization notify the donor of the value of the goods or services provided? c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form? d If ',' indicate the number of Forms filed during the year d e Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? g If the organization received a contribution of qualified intellectual property, did the organization file Form 99 as required? h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 09-C? Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? Sponsoring organizations maintaining donor advised funds. a Did the sponsoring organization make any taxable distributions under section 9? b Did the sponsoring organization make a distribution to a donor, donor advisor, or related person? Section 0(c)() organizations. Enter: a Initiation fees and capital contributions included on Part VIII, line b ross receipts, included on Form 990, Part VIII, line, for public use of club facilities..... Section 0(c)() organizations. Enter: a ross income from members or shareholders a b c e f g h 9a 9b 0 a 0 b a b ross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) b a Section 9(a)() non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 0? b If ',' enter the amount of tax-exempt interest received or accrued during the year b Section 0(c)(9) qualified nonprofit health insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state? te. See the instructions for additional information the organization must report on Schedule O. b Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans b c Enter the amount of reserves on hand c a Did the organization receive any payments for indoor tanning services during the tax year? b If ',' has it filed a Form 0 to report these payments? If ',' provide an explanation in Schedule O TEEA00L 0// a a a b Form 990 (0)

13 Page -999 overnance, Management, and Disclosure For each '' response to lines through b below, and for a '' response to line a, b, or 0b below, describe the circumstances, processes, or changes in Schedule O. See instructions. Check if Schedule O contains a response or note to any line in this Part VI Section A. overning Body and Management Form 990 (0) Part VI a Enter the number of voting members of the governing body at the end of the tax year a If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O. b Enter the number of voting members included in line a, above, who are independent b Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee?....see......schedule o Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors, or trustees, or key employees to a management company or other person? Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? Did the organization become aware during the year of a significant diversion of the organization's assets? Did the organization have members or stockholders? a Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? a b Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? b Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following: a The governing body? b Each committee with authority to act on behalf of the governing body? a b Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? If ',' provide the names and addresses in Schedule O Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.) 0 a Did the organization have local chapters, branches, or affiliates? b If ',' did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? b Describe in Schedule O the process, if any, used by the organization to review this Form 99 SEE SCHEDULE O a Did the organization have a written conflict of interest policy? If ',' go to line b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? c Did the organization regularly and consistently monitor and enforce compliance with the policy? If ',' describe in Schedule O how this was done Did the organization have a written whistleblower policy? Did the organization have a written document retention and destruction policy? Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? a The organization's CEO, Executive Director, or top management official b Other officers or key employees of the organization If '' to line a or b, describe the process in Schedule O (see instructions). 0 a 0 b a a b c a b a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? a b If ',' did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization's exempt status with respect to such arrangements? b Section C. Disclosure NJ List the states with which a copy of this Form 990 is required to be filed Section 0 requires an organization to make its Forms 0 (or 0 if applicable), 990, and 990-T (Section 0(c)()s only) available for public inspection. Indicate how you made these available. Check all that apply. Other (explain in Schedule O) Own website Another's website Upon request 9 Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year. SEE SCHEDULE O State the name, address, and telephone number of the person who possesses the organization's books and records: 0 CHARLES CASEY BARKMAN WAY CHESTER NJ TEEA00L 0// Form 990 (0)

14 Page -999 Part VII Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Form 990 (0) Check if Schedule O contains a response or note to any line in this Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization's tax year.? List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.? List all of the organization's current key employees, if any. See instructions for definition of 'key employee.'? List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (Box of Form W- and/or Box of Form 099-MISC) of more than 00,000 from the organization and any related organizations.? List all of the organization's former officers, key employees, and highest compensated employees who received more than 00,000 of reportable compensation from the organization and any related organizations.? List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than 0,000 of reportable compensation from the organization and any related organizations. List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest compensated employees; and former such persons. Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee. (C) () () () () () () () (A) (B) Name and Title Average hours per week (list any hours for related organizations below dotted line) FRANK LIHT, MD TRUSTEE DENNIS ZIOBAR TRUSTEE EVELYN DUDZIEC EECUTIVE DIR. MR. LEN DUDZIEC PRESIDENT CHARLES CASEY TREASURER TRACEY DE WAAL VICE PRESIDENT AMANDA MAJOR SECRETARY Position (do not check more than one box, unless person is both an officer and a director/trustee) (D) Reportable compensation from the organization (W-/099-MISC) (E) (F) Reportable compensation from related organizations (W-/099-MISC) Estimated amount of other compensation from the organization and related organizations () (9) (0) () () () () TEEA00L 0// Form 990 (0)

15 Page -999 Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) Form 990 (0) (B) (A) Name and title Average hours per week (list any hours for related organiza - tions below dotted line) (C) Position (do not check more than one box, unless person is both an officer and a director/trustee) (D) (E) (F) Reportable compensation from the organization (W-/099-MISC) Reportable compensation from related organizations (W-/099-MISC) Estimated amount of other compensation from the organization and related organizations () () () () (9) (0) () () () () () b Sub-total c Total from continuation sheets to Part VII, Section A d Total (add lines b and c) Total number of individuals (including but not limited to those listed above) who received more than 00,000 of reportable compensation from the organization 0 Did the organization list any former officer, director, or trustee, key employee, or highest compensated employee on line a? If ',' complete Schedule J for such individual For any individual listed on line a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than 0,000? If '' complete Schedule J for such individual Did any person listed on line a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If ',' complete Schedule J for such person Section B. Independent Contractors Complete this table for your five highest compensated independent contractors that received more than 00,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year. (A) Name and business address (B) Description of services (C) Compensation Total number of independent contractors (including but not limited to those listed above) who received more than 00,000 of compensation from the organization 0 TEEA00L 0// Form 990 (0)