Short Form Return of Organization Exempt From Income Tax

Transcription

1 Form 99-EZ Department of the Treasury Internal Revenue Service Short Form Return of Organization Exempt From Income Tax Website: Organization type (check only one) 51(c) ( 3 ) (insert no.) 4947(a)(1) or 527 OMB No A For the 28 calendar year, or tax year beginning 7/1, 28, and ending 6/3, 2 9 B Check if applicable: Please C Name of organization D Employer identification number Address change use IRS label or CENTRAL PENINSULA HEALTH FOUNDATION Name change print or Number and street (or P.O. box, if mail is not delivered to street address) Room/suite E Telephone number Initial return type. Termination See 25 Hospital Place ( 97 ) Specific Amended return City or town, state or country, and ZIP + 4 Instructions. Number F Group Exemption Application pending I J K Check if the organization is not a section 59(a)(3) supporting organization and its gross receipts are normally not more than $25,. A return is not required, but if the organization chooses to file a return, be sure to file a complete return. L Add lines 5b, 6b, and 7b, to line 9 to determine gross receipts; if $1,, or more, file Form 99 instead of Form 99-EZ $ 716,186 Part I Revenue, Expenses, and Changes in Net Assets or Fund Balances (See the instructions for Part I.) 1 Contributions, gifts, grants, and similar amounts received 1 699,586 2 Program service revenue including government fees and contracts 2 3 Membership dues and assessments 3 4 Investment income 4 5a Gross amount from sale of assets other than inventory 5a b Less: cost or other basis and sales expenses 5b c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) (attach schedule) 5c 6 Special events and activities (complete applicable parts of Schedule G). If any amount is from gaming, check here a Gross revenue (not including $ 63,617 of contributions reported on line 1) 6a 16,6 b Less: direct expenses other than fundraising expenses 6b 16,31 c Net income or (loss) from special events and activities (Subtract line 6b from line 6a) 6c 569 7a Gross sales of inventory, less returns and allowances 7a b Less: cost of goods sold 7b c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) 7c 8 Other revenue (describe ) 8 9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6c, 7c, and 8 9 7,155 1 Grants and similar amounts paid (attach schedule) See Statement , Benefits paid to or for members Salaries, other compensation, and employee benefits 12 75, Professional fees and other payments to independent contractors 13 4, Occupancy, rent, utilities, and maintenance 14 16, Printing, publications, postage, and shipping 15 1, Other expenses (describe See Statement 3 ) 16 19,73 17 Total expenses. Add lines 1 through , Excess or (deficit) for the year (Subtract line 17 from line 9) 18 63,39 19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end-of-year figure reported on prior year s return) ,85 2 Other changes in net assets or fund balances (attach explanation) See Statement 4 2 1, Net assets or fund balances at end of year. Combine lines 18 through ,263 Part II Balance Sheets. If Total assets on line 25, column (B) are $2,5, or more, file Form 99 instead of Form 99-EZ. Revenue Expenses Net Assets Under section 51(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation) Sponsoring organizations of donor advised funds and controlling organizations as defined in section 512(b)(13) must file Form 99. All other organizations with gross receipts less than $1,, and total assets less than $2,5, at the end of the year may use this form. The organization may have to use a copy of this return to satisfy state reporting requirements. Section 51(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A (Form 99 or 99-EZ). G Accounting method: Other (specify) 28 Open to Public Inspection (See the instructions for Part II.) (A) Beginning of year (B) End of year 22 Cash, savings, and investments 353, ,95 23 Land and buildings Other assets (describe See Statement 5 ) 41, , Total assets 394, , Total liabilities (describe See Statement 6 ) 121, ,38 27 Net assets or fund balances (line 27 of column (B) must agree with line 21) 273, ,263 For Privacy Act and Paperwork Reduction Act Notice, see the Instruction for Form 99. Cat. No. 1642I Form 99-EZ (28) Cash Accrual H Check if the organization is not required to attach Schedule B (Form 99, 99-EZ, or 99-PF).

2 Form 99-EZ (28) Page 2 Part III Statement of Program Service Accomplishments (See the instructions for Part III.) Expenses (Required for 51(c)(3) What is the organization s primary exempt purpose? To provide funding for activities, programs, and other s and (4) organizations Describe what was achieved in carrying out the organization s exempt purposes. In a clear and concise manner, and 4947(a)(1) trusts; describe the services provided, the number of persons benefited, or other relevant information for each program title. optional for others.) 28 See Statement 7 29 (Grants $ ) If this amount includes foreign grants, check here 28a 3 (Grants $ ) If this amount includes foreign grants, check here 29a (Grants $ ) If this amount includes foreign grants, check here 3a 31 Other program services (attach schedule) (Grants $ ) If this amount includes foreign grants, check here 31a 32 Total program service expenses (add lines 28a through 31a) ,865 Part IV List of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated. (See the instructions for Part IV.) (a) Name and address (b) Title and average hours per week devoted to position (c) Compensation (If not paid, enter --.) (d) Contributions to employee benefit plans & deferred compensation (e) Expense account and other allowances See Statement 8 Form 99-EZ (28)

3 Form 99-EZ (28) Part V Other Information (Note the statement requirements in the instructions for Part VI.) Did the organization engage in any activity not previously reported to the IRS? If Yes, attach a detailed description of each activity Were any changes made to the organizing or governing documents but not reported to the IRS? If Yes, attach a conformed copy of the changes If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but not reported on Form 99-T, attach a statement explaining your reason for not reporting the income on Form 99-T. a Did the organization have unrelated business gross income of $1, or more or section 633(e) notice, reporting, and proxy tax requirements? b If Yes, has it filed a tax return on Form 99-T for this year? 36 Was there a liquidation, dissolution, termination, or substantial contraction during the year? If Yes, complete applicable parts of Schedule N 37a Enter amount of political expenditures, direct or indirect, as described in the instructions. 37a b Did the organization file Form 112-POL for this year? 38a Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were any such loans made in a prior year and still unpaid at the start of the period covered by this return? 38a b If Yes, complete Schedule L, Part II and enter the total amount involved 38b 39 Section 51(c)(7) organizations. Enter: a Initiation fees and capital contributions included on line 9 39a b Gross receipts, included on line 9, for public use of club facilities 39b 4a Section 51(c)(3) organizations. Enter amount of tax imposed on the organization during the year under: section 4911 ; section 4912 ; section 4955 b Section 51(c)(3) and (4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year or did it become aware of an excess benefit transaction from a prior year? If Yes, complete Schedule L, Part I 4b c Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 d Enter amount of tax on line 4c reimbursed by the organization e All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If Yes, complete Form 8886-T. 4e 41 List the states with which a copy of this return is filed. 42a The books are in care of Peter Brennan Telephone no. ( 97 ) Located at 25 Hospital Place, ZIP b At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)? If Yes, enter the name of the foreign country: See the instructions for exceptions and filing requirements for Form TD F , Report of Foreign Bank and Financial Accounts. c At any time during the calendar year, did the organization maintain an office outside of the U.S.? If Yes, enter the name of the foreign country: 43 Section 4947(a)(1) nonexempt charitable trusts filing Form 99-EZ in lieu of Form 141 Check here and enter the amount of tax-exempt interest received or accrued during the tax year a 35b 36 37b 42b 42c Yes Page 3 No Yes No Did the organization maintain any donor advised funds? If Yes, Form 99 must be completed instead of Form 99-EZ Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)? If Yes, Form 99 must be completed instead of Form 99-EZ Yes No Form 99-EZ (28)

4 Form 99-EZ (28) Page 4 Part VI Section 51(c)(3) organizations only. All section 51(c)(3) organizations must answer questions and complete the tables for lines 5 and 51. Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to Yes No candidates for public office? If Yes, complete Schedule C, Part I Did the organization engage in lobbying activities? If Yes, complete Schedule C, Part II Is the organization operating a school as described in section 17(b)(1)(A)(ii)? If Yes, complete Schedule E 48 49a Did the organization make any transfers to an exempt non-charitable related organization? 49a b If Yes, was the related organization(s) a section 527 organization? 49b 5 Complete this table for the five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $1, of compensation from the organization. If there is none, enter None. None (a) Name and address of each employee paid more than $1, (b) Title and average hours per week devoted to position (c) Compensation (d) Contributions to employee benefit plans & deferred compensation (e) Expense account and other allowances Total number of other employees paid over $1, 51 Complete this table for the five highest compensated independent contractors who each received more than $1, of compensation from the organization. If there is none, enter None. None (a) Name and address of each independent contractor paid more than $1, (b) Type of service (c) Compensation Total number of other independent contractors each receiving over $1, Sign Here Paid Preparer s Use Only 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. Signature of officer Irv Carlisle, Treasurer Type or print name and title. Preparer s signature Date Check if selfemployed Firm s name (or yours EIN if self-employed), address, and ZIP + 4 Phone no. ( ) May the IRS discuss this return with the preparer shown above? See instructions Yes No Date Preparer s Identifying Number (See instructions) Form 99-EZ (28)

5 SCHEDULE A (Form 99 or 99-EZ) Department of the Treasury Internal Revenue Service Name of the organization Public Charity Status and Public Support Attach to Form 99 or Form 99-EZ. See separate instructions. OMB No Employer identification number CENTRAL PENINSULA HEALTH FOUNDATION Part I Reason for Public Charity Status (All organizations must complete this part.) (see instructions) The organization is not a private foundation because it is: (Please check only one organization.) 1 A church, convention of churches, or association of churches described in section 17(b)(1)(A)(i). 2 A school described in section 17(b)(1)(A)(ii). (Attach Schedule E.) 3 A hospital or a cooperative hospital service organization described in section 17(b)(1)(A)(iii). (Attach Schedule H.) 4 A medical research organization operated in conjunction with a hospital described in section 17(b)(1)(A)(iii). Enter the hospital s name, city, and state: 5 An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 17(b)(1)(A)(iv). (Complete Part II.) e f g h A federal, state, or local government or governmental unit described in section 17(b)(1)(A)(v). An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 17(b)(1)(A)(vi). (Complete Part II.) A community trust described in section 17(b)(1)(A)(vi). (Complete Part II.) An organization that normally receives: (1) more than % of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions subject to certain exceptions, and (2) no more than % of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 3, See section 59(a)(2). (Complete Part III.) An organization organized and operated exclusively to test for public safety. See section 59(a)(4). (see instructions) An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 59(a)(1) or section 59(a)(2). See section 59(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h. a Type I b Type II c Type III Functionally integrated d Type III Other By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 59(a)(1) or section 59(a)(2). If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box Since August 17, 26, has the organization accepted any gift or contribution from any of the following persons? (i) A person who directly or indirectly controls, either alone or together with persons described in (ii) and (iii) below, the governing body of the supported organization? (ii) A family member of a person described in (i) above? (iii) A 35% controlled entity of a person described in (i) or (ii) above? Provide the following information about the organizations the organization supports. (i) Name of supported organization To be completed by all section 51(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts. (ii) EIN (iii) Type of organization (described on lines 1 9 above or IRC section (see instructions)) (iv) Is the organization in col. (i) listed in your governing document? (v) Did you notify the organization in col. (i) of your support? (vi) Is the organization in col. (i) organized in the U.S.? Yes No Yes No Yes No 28 Open to Public Inspection 11g(i) 11g(ii) 11g(iii) Yes (vii) Amount of support No Total For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 99. Cat. No F Schedule A (Form 99 or 99-EZ) 28

6 Schedule A (Form 99 or 99-EZ) 28 Part II Support Schedule for Organizations Described in Sections 17(b)(1)(A)(iv) and 17(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I.) Section A. Public Support Calendar year (or fiscal year beginning in) (a) 24 (b) 25 (c) 26 (d) 27 (e) 28 (f) Total 1 2 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") Tax revenues levied for the organization s benefit and either paid to or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge 4 Total. Add lines The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) 6 Public support. Subtract line 5 from line 4. Section B. Total Support Calendar year (or fiscal year beginning in) Amounts from line 4 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources Net income from unrelated business activities, whether or not the business is regularly carried on (a) 24 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) Total support. Add lines 7 through 1 Gross receipts from related activities, etc. (see instructions) (b) 25 (c) Public support percentage for 28 (line 6, column (f) divided by line 11, column (f)) (d) 27 (e) 28 (f) Total 13 First five years. If the Form 99 is for the organization s first, second, third, fourth, or fifth tax year as a section 51(c)(3) organization, check this box and stop here Section C. Computation of Public Support Percentage 15 Public support percentage from 27 Schedule A, Part IV-A, line 26f 16a % support test 28. If the organization did not check the box on line 13, and line 14 is % or more, check this box and stop here. The organization qualifies as a publicly supported organization b 17a % support test 27. If the organization did not check a box on line 13 or 16a, and line 15 is % or more, check this box and stop here. The organization qualifies as a publicly supported organization 1%-facts-and-circumstances test 28. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 1% or more, and if the organization meets the facts-and-circumstances test, check this box and stop here. Explain in Part IV how the organization meets the facts-and-circumstances test. The organization qualifies as a publicly supported organization b 1%-facts-and-circumstances test 27. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 1% or more, and if the organization meets the facts-and-circumstances test, check this box and stop here. Explain in Part IV how the organization meets the facts-and-circumstances test. The organization qualifies as a publicly supported organization 18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions Page 2 % % Schedule A (Form 99 or 99-EZ) 28

7 Schedule A (Form 99 or 99-EZ) 28 Part III Support Schedule for Organizations Described in Section 59(a)(2) (Complete only if you checked the box on line 9 of Part I.) Section A. Public Support Calendar year (or fiscal year beginning in) (a) 24 (b) 25 (c) 26 (d) 27 (e) 28 (f) Total Page Gifts, grants, contributions, and membership 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 3 Gross receipts from activities that are not an unrelated trade or business under section Tax revenues levied for the organization s benefit and either paid to or expended on its behalf 5 The value of services or facilities furnished by a governmental unit to the organization without charge 6 Total. Add lines 1-5 7a Amounts included on lines 1, 2, and 3 received from disqualified persons b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of 1% of the total of lines 9, 1c, 11, and 12 for the year or $5, c Add lines 7a and 7b 8 Public support (Subtract line 7c from line 6.) Section B. Total Support Calendar year (or fiscal year beginning in) 9 1a Amounts from line 6 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 3, 1975 c Add lines 1a and 1b 11 Net income from unrelated business activities not included in line 1b, whether or not the business is regularly carried on (a) 24 91, , ,586 1,83,283 91, , ,586 1,83,283 25, 5, 3, 21, 198,795 43,784 65,579 46, 23,795 43,784 68,579 42,74 (b) 25 (c) 26 (d) 27 (e) 28 (f) Total 91, , ,586 1,83,283-11,5-38,7-49,75-11,5-38,7-49,75 12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) 13 Total support. (Add lines 9, 1c, 11, and 12.) 1,33, First five years. If the Form 99 is for the organization s first, second, third, fourth, or fifth tax year as a section 51(c)(3) organization, check this box and stop here Section C. Computation of Public Support Percentage 15 Public support percentage for 28 (line 8, column (f) divided by line 13, column (f)) 16 Public support percentage from 27 Schedule A, Part IV-A, line 27g Section D. Computation of Investment Income Percentage 17 Investment income percentage for 28 (line 1c, column (f) divided by line 13, column (f)) 17 % 18 Investment income percentage from 27 Schedule A, Part IV-A, line 27h 18 % 19a % support tests 28. If the organization did not check the box on line 14, and line 15 is more than %, and line 17 is not more than %, check this box and stop here. The organization qualifies as a publicly supported organization b % support tests 27. If the organization did not check a box on line 14 or line 19a, and line 16 is more than %, and line 18 is not more than %, check this box and stop here. The organization qualifies as a publicly supported organization 2 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions % % Schedule A (Form 99 or 99-EZ) 28

8 Schedule A (Form 99 or 99-EZ) 28 Part IV Supplemental Information. Complete this part to provide the explanation required by Part II, line 1; Part II, line 17a or 17b; or Part III, line 12. Provide any other additional information. (see instructions) Page 4 Schedule A (Form 99 or 99-EZ) 28

9 SCHEDULE G (Form 99 or 99-EZ) Department of the Treasury Internal Revenue Service Name of the organization CENTRAL PENINSULA HEALTH FOUNDATION Supplemental Information Regarding Fundraising or Gaming Activities Attach to Form 99 or Form 99-EZ. Must be completed by organizations that answer Yes to Form 99, Part IV, lines 17, 18, or 19, and by organizations that enter more than $15, on Form 99-EZ, line 6a. OMB No Open To Public Inspection Employer identification number Part I Fundraising Activities. Complete if the organization answered Yes to Form 99, Part IV, line Indicate whether the organization raised funds through any of the following activities. Check all that apply. a Mail solicitations e Solicitation of non-government grants b solicitations f Solicitation of government grants c Phone solicitations g Special fundraising events d In-person solicitations 2a b Did the organization have a written or oral agreement with any individual (including officers, directors, trustees or key employees listed in Form 99, 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 be compensated at least $5, by the organization. Form 99-EZ filers are not required to complete this table. Yes No (i) Name of individual or entity (fundraiser) (ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts from activity (v) Amount paid to (or retained by) fundraiser listed in col. (i) (vi) Amount paid to (or retained by) organization Yes No Total 3 List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing. For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 99. Cat. No. 583H Schedule G (Form 99 or 99-EZ) 28

10 Schedule G (Form 99 or 99-EZ) 28 Part II Fundraising Events. Complete if the organization answered Yes to Form 99, Part IV, line 18, or reported more than $15, on Form 99-EZ, line 6a. List events with gross receipts greater than $5,. (a) Event #1 Way out women sn (b) Event #2 29 Evening by th (c) Other Events (event type) (event type) (total number) (d) Total Events (Add col. (a) through col. (c)) Page 2 Revenue Gross receipts Less: Charitable contributions Gross revenue (line 1 minus line 2) 36,667 36,667 43,55 26,95 16,6 8,217 63,617 16,6 4 Cash prizes Direct Expenses Non-cash prizes Rent/facility costs Other direct expenses , ,456 8 Direct expense summary. Add lines 4 through 7 in column (d) ( 16,31) 9 Net income summary. Combine lines 3 and 8 in column (d) 569 Part III Gaming. Complete if the organization answered Yes to Form 99, Part IV, line 19, or reported more than $15, on Form 99-EZ, line 6a. Revenue 1 Gross revenue (a) Bingo (b) Pull tabs/instant bingo/progressive bingo (c) Other gaming (d) Total gaming (Add col. (a) through col. (c)) Direct Expenses Cash prizes Non-cash prizes Rent/facility costs 5 6 Other direct expenses Volunteer labor Yes No % Yes No % Yes No % 7 Direct expense summary. Add lines 2 through 5 in column (d) ( ) 8 Net gaming income summary. Combine lines 1 and 7 in column (d) 9 Enter the state(s) in which the organization operates gaming activities: a Is the organization licensed to operate gaming activities in each of these states? b If No, Explain: 9a Yes No 1a b Were any of the organization s gaming licenses revoked, suspended or terminated during the tax year? If Yes, Explain: 1a Does the organization operate gaming activities with nonmembers? Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity formed to administer charitable gaming? Schedule G (Form 99 or 99-EZ) 28

11 Schedule G (Form 99 or 99-EZ) Indicate the percentage of gaming activity operated in: a b The organization s facility An outside facility 13a 13b % % 14 Provide the name and address of the person who prepares the organization s gaming/special events books and records: Page 3 Yes No Name Address 15a Does the organization have a contract with a third party from whom the organization receives gaming revenue? b If Yes, enter the amount of gaming revenue received by the organization $ and the amount of gaming revenue retained by the third party $. c If Yes, enter name and address: 15a Name Address 16 Gaming manager information: Name Gaming manager compensation $ Description of services provided Director/officer Employee Independent contractor 17 a b Mandatory distributions: Is the organization required under state law to make charitable distributions from the gaming proceeds to retain the state gaming license? Enter the amount of distributions required under state law distributed to other exempt organizations or spent in the organization s own exempt activities during the tax year $ 17a Schedule G (Form 99 or 99-EZ) 28

12 Statement 1 : General Explanations Statement 2 : Grants and Similar Amounts Paid Statement 3 : Other Expenses Schedule Statement 4 : Other Changes In Net Assets Schedule Statement 5 : Other Assets Statement 6 : Liabilities Schedule Statement 7 : Program Service Accomplishments Statement 8 : Officers, Directors, Trustees and Key Employees Compensation Page: 1

13 Statement 1 CENTRAL PENINSULA HEALTH FOUNDATION Form: 99-EZ Page: 1 Line Number: GeneralExplanationAttachment General Explanations Reference: Form 99-EZ, Part I, Line 6 Identifier: F99ZP1SL6 Explanation: Page: 2

14 Statement 2 CENTRAL PENINSULA HEALTH FOUNDATION Form: 99-EZ Page: 1 Line Number: Part I Line 1 GrantsAndSimilarAmountsPaidSchedule Grants and Similar Amounts Paid BookValue FMV Amount Type of Activity: Capital grants and other assistance $424,863 Donee's name and Central Peninsula General Hospital address: 25 Hospital Place Purpose of Capital grants and other assistance payment to affiliate: Relationship: Description: How Book Value Determined: How FMV Determined: Date of Gift: Type of Activity: Grants and assistance to individuals $82,784 Donee's name and Central Peninsula General Hospital address: 25 Hospital Place Purpose of payment to affiliate: Funding for individual assistance grants for cancer treatment, transportation, and emergency assist. Relationship: Description: How Book Value Determined: How FMV Determined: Date of Gift: Total: $ $57,647 Page: 3

15 Statement 3 CENTRAL PENINSULA HEALTH FOUNDATION Form: 99-EZ Page: 1 Line Number: Part I Line 16 OtherExpensesSchedule2 Other Expenses Schedule Description Amount Conferences and meetings $1,652 Depreciation $2,1 Fundraising expenses $13,664 Membership dues $74 Bank fees $59 Organizational expenses $215 Bad debt expense $85 Total: $19,73 Page: 4

16 Statement 4 CENTRAL PENINSULA HEALTH FOUNDATION Form: 99-EZ Page: 1 Line Number: Part I Line 2 OtherChangesInNetAssetsSchedule Other Changes In Net Assets Schedule Description Amount Loss on investments ($38,7) Correction made to prior year net assets $49,488 Total: $1,788 Page: 5

17 Statement 5 CENTRAL PENINSULA HEALTH FOUNDATION Form: 99-EZ Page: 1 Line Number: Part II Line 24 OtherAssetsSchedule3 Other Assets BOY EOY Description Amount Amount Pledges receivable $35,893 $47,436 Equipment $5,711 $14,34 Restricted investment $ $32,998 Total: $41,64 $94,738 Page: 6

18 Statement 6 CENTRAL PENINSULA HEALTH FOUNDATION Form: 99-EZ Page: 1 Line Number: Part II Line 26 OtherLiabilitiesSchedule3 Liabilities Schedule Description BOY EOY Amount Amount Accounts payable and accrued expenses $94,59 $14,5 Custodial account for CPH $27,51 $11,375 Total: $121,641 $25,38 Page: 7

19 Statement 7 CENTRAL PENINSULA HEALTH FOUNDATION Form: 99-EZ Page: 2 Line Number: Part III Line 28 ProgramServiceAccomplishmentStatement Program Service Accomplishments includes Program Grants And Foreign Service Achievement Allocations Grants Expenses Central Peninsula Health Foundation assisted in the procurement of grants and other public support necessary to purchase a facility for Serenity House, the chemical dependency unit of Central Peninsula General Hospital. Grants and revenues in the amount of $345,5 were collected during the current tax year, while other revenues were earned in the prior tax year. Total distributions of $392,361 were made to Central Peninsula General Hospital for this capital purchase. $345, $392,361 Other program service accomplishments include direct assistance to individuals for various needs such as Cancer Treatment $75,925, Employee emergency assistance $9,94, and other costs for services and supplies to support Central Peninsula Hospital programs $68,485. $ $153,54 Total: $545,865 Page: 8

20 Statement 8 CENTRAL PENINSULA HEALTH FOUNDATION Form: 99-EZ Page: 2 Line Number: Part IV OfficersDirectorsEtcStatement Officers, Directors, Trustees and Key Employees Compensation Name Title and Hrs Compensation Benefits Expense Rick Abbott Board Member $ $ $ 25 Hospital Place 1 Dr Charles Bailie Board Member $ $ $ 25 Hospital Place 1 Charles Obendorf Treasurer $ $ $ 25 Hospital Place 2 Sky Carver Secretary $ $ $ 25 Hospital Place 2 Ed Krohn President $ $ $ 25 Hospital Place 2 Dr Alex Russell Board Member $ $ $ 25 Hospital Place 1 Dr Scott Innes Board Member $ $ $ 25 Hospital Place 1 Janie Finley Board Member $ $ $ 25 Hospital Place 1 Terri Davis Board Member $ $ $ 25 Hospital Place 1 Betty Glick Board member $ $ $ 25 Hospital Place 1 Pat Cowan Vice President $ $ $ 25 Hospital Place 2 Peter Brennan Foundation Director $83,33 $27,45 25 Hospital Place 4 Total: $83,33 $27,45 $ Page: 9