Return of Organization Exempt From Income Tax

Transcription

1 Form B Open to Puli Inspetion The organization may have to use a opy of this return to satisfy state reporting requirements July June For the alenar year, or tax year eginning,, an ening, Chek if appliale: C Name of organization WI Family Assistane Center for Euation, Training, an Supp D Employer ientifiation numer - Doing Business As WI FACETS Aress hange Numer an street (or PO ox if mail is not elivere to street aress) Name hange Uner setion (), 7, or 7(a)() of the Internal Revenue Coe (exept lak lung enefit trust or private founation) Department of the Treasury Internal Revenue Servie A OMB -7 Return of Organization Exempt From Inome Tax West Virginia Street Initial return E Telephone numer Room/suite Suite Milwaukee, WI Amene return G Gross reeipts $ Rohelle Upright-Sexton, Presient West Virginia Street, Suite, Milwaukee, WI Appliation pening F Name an aress of prinipal offier: I Tax-exempt status: J K Wesite: Form of organization: Ativities & Governane ()() ) (insert no) () ( 7(a)() or H(a) Is this a group return for affiliates? 7 Corporation H() Group exemption numer Trust Assoiation Other L Year of formation: Revenue Expenses WI M State of legal omiile: Summary Briefly esrie the organization s mission or most signifiant ativities: The mission of WI FACETS is to provie an roaen opportunities that enhane the quality of life for hilren an aults with isailities an their families with an emphasis on support for uner-serve families in the ommunity We provie information, training an iniviual support 7a Chek this ox if the organization isontinue its operations or ispose of more than % of its net assets Numer of voting memers of the governing oy (Part VI, line a) Numer of inepenent voting memers of the governing oy (Part VI, line ) Total numer of iniviuals employe in alenar year (Part V, line a) Total numer of volunteers (estimate if neessary) Total unrelate usiness revenue from Part VIII, olumn (C), line 7a Net unrelate usiness taxale inome from Form -T, line 7 Prior Year Net Assets or Fun Balanes H() Are all affiliates inlue? If, attah a list (see instrutions) wwwwifaetsorg Part I -7- City or town, state or ountry, an ZIP + Terminate a 7 Contriutions an grants (Part VIII, line h) Program servie revenue (Part VIII, line g) Investment inome (Part VIII, olumn (A), lines,, an 7) Other revenue (Part VIII, olumn (A), lines,,,,, an e) Total revenue a lines through (must equal Part VIII, olumn (A), line ) Grants an similar amounts pai (Part IX, olumn (A), lines ) Benefits pai to or for memers (Part IX, olumn (A), line ) Salaries, other ompensation, employee enefits (Part IX, olumn (A), lines ) Professional funraising fees (Part IX, olumn (A), line e) Total funraising expenses (Part IX, olumn (D), line ) Other expenses (Part IX, olumn (A), lines a, f e) Total expenses A lines 7 (must equal Part IX, olumn (A), line ) Revenue less expenses Sutrat line from line Total assets (Part X, line ) Total liailities (Part X, line ) Net assets or fun alanes Sutrat line from line Part II Current Year En of Year Beginning of Current Year 7 Signature Blok Uner penalties of perjury, I elare that I have examine this return, inluing aompanying sheules an statements, an to the est of my knowlege an elief, it is true, orret, an omplete Delaration of preparer (other than offier) is ase on all information of whih preparer has any knowlege Sign Here Pai Preparer Use Only Date Signature of offier Type or print name an title Print/Type preparer s name Preparer's signature Date Chek if self-employe Firm s name Firm's EIN Firm's aress Phone no May the IRS isuss this return with the preparer shown aove? (see instrutions) For Paperwork Reution At tie, see the separate instrutions Cat Y PTIN Form ()

2 Page Form () Part III Statement of Program Servie Aomplishments Chek if Sheule O ontains a response to any question in this Part III Briefly esrie the organization s mission: The mission of WI FACETS is: To provie an to roaen opportunities that enhane the quality of life for hilren an aults with isailities, with an emphasis on support for unerserve parents/families in the ommunity Di the organization unertake any signifiant program servies uring the year whih were not liste on the prior Form or -EZ? If, esrie these new servies on Sheule O Di the organization ease onuting, or make signifiant hanges in how it onuts, any program servies? If, esrie these hanges on Sheule O Desrie the organization's program servie aomplishments for eah of its three largest program servies, as measure y expenses Setion ()() an ()() organizations an setion 7(a)() trusts are require to report the amount of grants an alloations to others, the total expenses, an revenue, if any, for eah program servie reporte a (Coe: 7 inluing grants of $ ) (Expenses $ Parent Training an Information Center (PTIC/US DOE-OSEP grant) ) (Revenue $ ) Purpose: provie training, information an support to families of hilren with isailities an others in WI; # serve:, reahe through training, alls, letters, an (,7 ulturally-iverse);, serve in exhiits, meia, newsletters, an listserves;, we visits Puliations: Shool Choie for Stuents with Disailities & FAQ; IMPACT: Impat of - Biennial Buget on Stuents with Disailities; Outomes: % of parents surveye felt more knowlegeale aout how to work with shools; % iniate information they reeive was useful; % sai they ha information neee to make eisions aout their hil's euation (Coe: 7 inluing grants of $ 77 ) (Revenue $ ) (Expenses $ Region Parent Tehnial Assistane Center (PTAC/US DOE-OSEP Cooperative Agreement) ) Purpose: Provision of tehnial assistane to OSEP-fune parent enter in Region # serve: enters in states (IA, IL, IN, MI, MN, MO, OH, PA, an WI) reeive support; attene annual onf; weinars & workshops provie; over,7 wesite visits (wwwregionus; wwwparententernetworkorg/region): Region PTAC Yahoo group reahe,; iret tehnial assistane of over, phone alls an ; site visits; Puliations: Region Insier quarterly e-newsletter; R Conferene Partiipant Paket Outomes: % of enters visite rate assistane reeive as useful an of high quality; % of training partiipants rate it as high quality an useful; % felt the information was relevant to their work (Coe: ) (Expenses $ 77 inluing grants of $ ) (Revenue $ ) State Personnel Development Grant (WI DPI grant) Purpose: to improve results for hilren with isailities y assisting the WI Dept of Puli Instrution (WDPI) to improve state systems for proviing euational, early intervention, an transitional servies through use of the WI Personnel Development Moel Puliations: Guieook: Serving on Groups that Make Deisions (Spanish); Training of Trainers Curriulum; Guieook vieo The Parent Leaership Hu weekly E-Newsletter inlue family involvement resoures an professional evelopment opportunities; trainers traine; workshops provie on Guieook; presentations at onferenes in WI at National CEC 7 traine on Guieook % felt the training to e of high quality; 7% iniate it to e useful an relevant to their nees Stipens provie to support attenane of parents of hilren irth to to atten a st-time professional evelopment event - one parent's summary report note, "it was a life-hanging experiene for me" 7% of newsletter reipients rate it as high quality an % reporte giving it to other parents Outomes: inrease the numer an apaity of parents an youth partiipating in professional evelopmet opportunities; inrease apaity to use researh-ase professional evelopment moel; inrease apaity to serve on eision-making groups Other program servies (Desrie in Sheule O) (Expenses $ 7 inluing grants of $ ) (Revenue $ e Total program servie expenses ) Form ()

3 Page Form () Part IV Cheklist of Require Sheules Is the organization esrie in setion ()() or 7(a)() (other than a private founation)? If, omplete Sheule A Is the organization require to omplete Sheule B, Sheule of Contriutors (see instrutions)? Di the organization engage in iret or iniret politial ampaign ativities on ehalf of or in opposition to aniates for puli offie? If, omplete Sheule C, Part I Setion ()() organizations Di the organization engage in loying ativities, or have a setion (h) eletion in effet uring the tax year? If, omplete Sheule C, Part II Is the organization a setion ()(), ()(), or ()() organization that reeives memership ues, assessments, or similar amounts as efine in Revenue Proeure -? If, omplete Sheule C, Part III Di the organization maintain any onor avise funs or any similar funs or aounts for whih onors have the right to provie avie on the istriution or investment of amounts in suh funs or aounts? If, omplete Sheule D, Part I Di the organization reeive or hol a onservation easement, inluing easements to preserve open spae, the environment, histori lan areas, or histori strutures? If, omplete Sheule D, Part II Di the organization maintain olletions of works of art, historial treasures, or other similar assets? If, omplete Sheule D, Part III 7 Di the organization report an amount in Part X, line ; serve as a ustoian for amounts not liste in Part X; or provie reit ounseling, et management, reit repair, or et negotiation servies? If, omplete Sheule D, Part IV a Di the organization, iretly or through a relate organization, hol assets in temporarily restrite enowments, permanent enowments, or quasi-enowments? If, omplete Sheule D, Part V If the organization s answer to any of the following questions is, then omplete Sheule D, Parts VI, VII, VIII, IX, or X as appliale Di the organization report an amount for lan, uilings, an equipment in Part X, line? If, omplete Sheule D, Part VI Di the organization report an amount for investments other seurities in Part X, line that is % or more of its total assets reporte in Part X, line? If, omplete Sheule D, Part VII Di the organization report an amount for investments program relate in Part X, line that is % or more of its total assets reporte in Part X, line? If, omplete Sheule D, Part VIII Di the organization report an amount for other assets in Part X, line that is % or more of its total assets reporte in Part X, line? If, omplete Sheule D, Part IX e Di the organization report an amount for other liailities in Part X, line? If, omplete Sheule D, Part X f Di the organization s separate or onsoliate finanial statements for the tax year inlue a footnote that aresses the organization s liaility for unertain tax positions uner FIN (ASC 7)? If, omplete Sheule D, Part X a Di the organization otain separate, inepenent auite finanial statements for the tax year? If, omplete Sheule D, Parts XI, XII, an XIII Was the organization inlue in onsoliate, inepenent auite finanial statements for the tax year? If, an if the organization answere "" to line a, then ompleting Sheule D, Parts XI, XII, an XIII is optional Is the organization a shool esrie in setion 7()()(A)(ii)? If, omplete Sheule E a Di the organization maintain an offie, employees, or agents outsie of the Unite States? Di the organization have aggregate revenues or expenses of more than $, from grantmaking, funraising, usiness, investment, an program servie ativities outsie the Unite States, or aggregate foreign investments value at $, or more? If, omplete Sheule F, Parts I an IV Di the organization report on Part IX, olumn (A), line, more than $, of grants or assistane to any organization or entity loate outsie the Unite States? If, omplete Sheule F, Parts II an IV Di the organization report on Part IX, olumn (A), line, more than $, of aggregate grants or assistane to iniviuals loate outsie the Unite States? If, omplete Sheule F, Parts III an IV 7 Di the organization report a total of more than $, of expenses for professional funraising servies on Part IX, olumn (A), lines an e? If, omplete Sheule G, Part I (see instrutions) Di the organization report more than $, total of funraising event gross inome an ontriutions on Part VIII, lines an a? If, omplete Sheule G, Part II Di the organization report more than $, of gross inome from gaming ativities on Part VIII, line a? If, omplete Sheule G, Part III a Di the organization operate one or more hospital failities? If, omplete Sheule H If to line a, i the organization attah a opy of its auite finanial statements to this return? 7 a e f a a 7 a Form ()

4 Page Form () Part IV Cheklist of Require Sheules (ontinue) Di the organization report more than $, of grants an other assistane to any government or organization in the Unite States on Part IX, olumn (A), line? If, omplete Sheule I, Parts I an II Di the organization report more than $, of grants an other assistane to iniviuals in the Unite States on Part IX, olumn (A), line? If, omplete Sheule I, Parts I an III Di the organization answer to Part VII, Setion A, line,, or aout ompensation of the organization s urrent an former offiers, iretors, trustees, key employees, an highest ompensate employees? If, omplete Sheule J a Di the organization have a tax-exempt on issue with an outstaning prinipal amount of more than $, as of the last ay of the year, that was issue after Deemer,? If, answer lines through an omplete Sheule K If, go to line Di the organization invest any proees of tax-exempt ons eyon a temporary perio exeption? Di the organization maintain an esrow aount other than a refuning esrow at any time uring the year to efease any tax-exempt ons? Di the organization at as an on ehalf of issuer for ons outstaning at any time uring the year? a Setion ()() an ()() organizations Di the organization engage in an exess enefit transation with a isqualifie person uring the year? If, omplete Sheule L, Part I Is the organization aware that it engage in an exess enefit transation with a isqualifie person in a prior year, an that the transation has not een reporte on any of the organization s prior Forms or -EZ? If, omplete Sheule L, Part I Was a loan to or y a urrent or former offier, iretor, trustee, key employee, highly ompensate employee, or isqualifie person outstaning as of the en of the organization s tax year? If, omplete Sheule L, Part II 7 Di the organization provie a grant or other assistane to an offier, iretor, trustee, key employee, sustantial ontriutor or employee thereof, a grant seletion ommittee memer, or to a % ontrolle entity or family memer of any of these persons? If, omplete Sheule L, Part III Was the organization a party to a usiness transation with one of the following parties (see Sheule L, Part IV instrutions for appliale filing threshols, onitions, an exeptions): a A urrent or former offier, iretor, trustee, or key employee? If, omplete Sheule L, Part IV A family memer of a urrent or former offier, iretor, trustee, or key employee? If, omplete Sheule L, Part IV An entity of whih a urrent or former offier, iretor, trustee, or key employee (or a family memer thereof) was an offier, iretor, trustee, or iret or iniret owner? If, omplete Sheule L, Part IV Di the organization reeive more than $, in non-ash ontriutions? If, omplete Sheule M Di the organization reeive ontriutions of art, historial treasures, or other similar assets, or qualifie onservation ontriutions? If, omplete Sheule M Di the organization liquiate, terminate, or issolve an ease operations? If, omplete Sheule N, Part I Di the organization sell, exhange, ispose of, or transfer more than % of its net assets? If, omplete Sheule N, Part II Di the organization own % of an entity isregare as separate from the organization uner Regulations setions 77- an 77-? If, omplete Sheule R, Part I Was the organization relate to any tax-exempt or taxale entity? If, omplete Sheule R, Parts II, III, IV, an V, line a Di the organization have a ontrolle entity within the meaning of setion ()()? Di the organization reeive any payment from or engage in any transation with a ontrolle entity within the meaning of setion ()()? If, omplete Sheule R, Part V, line Setion ()() organizations Di the organization make any transfers to an exempt non-haritale relate organization? If, omplete Sheule R, Part V, line 7 Di the organization onut more than % of its ativities through an entity that is not a relate organization an that is treate as a partnership for feeral inome tax purposes? If, omplete Sheule R, Part VI Di the organization omplete Sheule O an provie explanations in Sheule O for Part VI, lines an? te All Form filers are require to omplete Sheule O a a 7 a a 7 Form ()

5 Page Form () Part V Statements Regaring Other IRS Filings an Tax Compliane Chek if Sheule O ontains a response to any question in this Part V a Enter the numer reporte in Box of Form Enter -- if not appliale a Enter the numer of Forms W-G inlue in line a Enter -- if not appliale Di the organization omply with akup withholing rules for reportale payments to venors an reportale gaming (gamling) winnings to prize winners? a Enter the numer of employees reporte on Form W-, Transmittal of Wage an Tax Statements, file for the alenar year ening with or within the year overe y this return a If at least one is reporte on line a, i the organization file all require feeral employment tax returns? te If the sum of lines a an a is greater than, you may e require to e-file (see instrutions) a Di the organization have unrelate usiness gross inome of $, or more uring the year? If, has it file a Form -T for this year? If, provie an explanation in Sheule O a At any time uring the alenar year, i the organization have an interest in, or a signature or other authority over, a finanial aount in a foreign ountry (suh as a ank aount, seurities aount, or other finanial aount)? If, enter the name of the foreign ountry: See instrutions for filing requirements for Form TD F -, Report of Foreign Bank an Finanial Aounts a Was the organization a party to a prohiite tax shelter transation at any time uring the tax year? Di any taxale party notify the organization that it was or is a party to a prohiite tax shelter transation? If to line a or, i the organization file Form -T? a Does the organization have annual gross reeipts that are normally greater than $,, an i the organization soliit any ontriutions that were not tax eutile? If, i the organization inlue with every soliitation an express statement that suh ontriutions or gifts were not tax eutile? 7 Organizations that may reeive eutile ontriutions uner setion 7() a Di the organization reeive a payment in exess of $7 mae partly as a ontriution an partly for goos an servies provie to the payor? a a a a If, i the organization notify the onor of the value of the goos or servies provie? Di the organization sell, exhange, or otherwise ispose of tangile personal property for whih it was require to file Form? e f g h a a a a a If, iniate the numer of Forms file uring the year 7 Di the organization reeive any funs, iretly or iniretly, to pay premiums on a personal enefit ontrat? Di the organization, uring the year, pay premiums, iretly or iniretly, on a personal enefit ontrat? If the organization reeive a ontriution of qualifie intelletual property, i the organization file Form as require? If the organization reeive a ontriution of ars, oats, airplanes, or other vehiles, i the organization file a Form -C? Sponsoring organizations maintaining onor avise funs an setion (a)() supporting organizations Di the supporting organization, or a onor avise fun maintaine y a sponsoring organization, have exess usiness holings at any time uring the year? Sponsoring organizations maintaining onor avise funs Di the organization make any taxale istriutions uner setion? Di the organization make a istriution to a onor, onor avisor, or relate person? Setion ()(7) organizations Enter: a Initiation fees an apital ontriutions inlue on Part VIII, line Gross reeipts, inlue on Form, Part VIII, line, for puli use of lu failities Setion ()() organizations Enter: a Gross inome from memers or shareholers Gross inome from other soures (Do not net amounts ue or pai to other soures against amounts ue or reeive from them) Setion 7(a)() non-exempt haritale trusts Is the organization filing Form in lieu of Form? If, enter the amount of tax-exempt interest reeive or arue uring the year Setion ()() qualifie nonprofit health insurane issuers Is the organization liense to issue qualifie health plans in more than one state? te See the instrutions for aitional information the organization must report on Sheule O Enter the amount of reserves the organization is require to maintain y the states in whih the organization is liense to issue qualifie health plans Enter the amount of reserves on han a Di the organization reeive any payments for inoor tanning servies uring the tax year? If "," has it file a Form 7 to report these payments? If "," provie an explanation in Sheule O 7a 7 7 7e 7f 7g 7h a a a a Form ()

6 Page Governane, Management, an Dislosure For eah response to lines through 7 elow, an for a response to line a,, or elow, esrie the irumstanes, proesses, or hanges in Sheule O See instrutions Form () Part VI Chek if Sheule O ontains a response to any question in this Part VI Setion A Governing Boy an Management a Enter the numer of voting memers of the governing oy at the en of the tax year If there are material ifferenes in voting rights among memers of the governing oy, or if the governing oy elegate roa authority to an exeutive ommittee or similar ommittee, explain in Sheule O a Enter the numer of voting memers inlue in line a, aove, who are inepenent Di any offier, iretor, trustee, or key employee have a family relationship or a usiness relationship with any other offier, iretor, trustee, or key employee? Di the organization elegate ontrol over management uties ustomarily performe y or uner the iret supervision of offiers, iretors, or trustees, or key employees to a management ompany or other person? 7a Di the organization make any signifiant hanges to its governing ouments sine the prior Form was file? Di the organization eome aware uring the year of a signifiant iversion of the organization s assets? Di the organization have memers or stokholers? Di the organization have memers, stokholers, or other persons who ha the power to elet or appoint one or more memers of the governing oy? Are any governane eisions of the organization reserve to (or sujet to approval y) memers, stokholers, or persons other than the governing oy? Di the organization ontemporaneously oument the meetings hel or written ations unertaken uring the year y the following: a The governing oy? Eah ommittee with authority to at on ehalf of the governing oy? Is there any offier, iretor, trustee, or key employee liste in Part VII, Setion A, who annot e reahe at the organization s mailing aress? If, provie the names an aresses in Sheule O 7a 7 a Setion B Poliies (This Setion B requests information aout poliies not require y the Internal Revenue Coe) a Di the organization have loal hapters, ranhes, or affiliates? If, i the organization have written poliies an proeures governing the ativities of suh hapters, affiliates, an ranhes to ensure their operations are onsistent with the organization's exempt purposes? a Has the organization provie a omplete opy of this Form to all memers of its governing oy efore filing the form? Desrie in Sheule O the proess, if any, use y the organization to review this Form a Di the organization have a written onflit of interest poliy? If, go to line Were offiers, iretors, or trustees, an key employees require to islose annually interests that oul give rise to onflits? Di the organization regularly an onsistently monitor an enfore ompliane with the poliy? If, esrie in Sheule O how this was one Di the organization have a written whistlelower poliy? Di the organization have a written oument retention an estrution poliy? Di the proess for etermining ompensation of the following persons inlue a review an approval y inepenent persons, omparaility ata, an ontemporaneous sustantiation of the elieration an eision? a The organization s CEO, Exeutive Diretor, or top management offiial Other offiers or key employees of the organization If to line a or, esrie the proess in Sheule O (see instrutions) a Di the organization invest in, ontriute assets to, or partiipate in a joint venture or similar with a taxale entity uring the year? a a a a arrangement a If, i the organization follow a written poliy or proeure requiring the organization to evaluate its partiipation in joint venture arrangements uner appliale feeral tax law, an take steps to safeguar the organization s exempt status with respet to suh arrangements? Setion C Dislosure 7 Wisonsin List the states with whih a opy of this Form is require to e file Setion requires an organization to make its Forms (or if appliale),, an -T (Setion ()()s only) availale for puli inspetion Iniate how you mae these availale Chek all that apply Another s wesite Upon request Own wesite Desrie in Sheule O whether (an if so, how), the organization mae its governing ouments, onflit of interest poliy, an finanial statements availale to the puli uring the tax year State the name, physial aress, an telephone numer of the person who possesses the ooks an reors of the organization: Janis Serak, Exeutive Co-Diretor; W Virginia Street, Suite, Milwaukee, WI ; -7- Form ()

7 Page 7 Compensation of Offiers, Diretors, Trustees, Key Employees, Highest Compensate Employees, an Inepenent Contrators Form () Part VII Chek if Sheule O ontains a response to any question in this Part VII Setion A Offiers, Diretors, Trustees, Key Employees, an Highest Compensate Employees a Complete this tale for all persons require to e liste Report ompensation for the alenar year ening with or within the organization s tax year List all of the organization s urrent offiers, iretors, trustees (whether iniviuals or organizations), regarless of amount of ompensation Enter -- in olumns (D), (E), an (F) if no ompensation was pai List all of the organization s urrent key employees, if any See instrutions for efinition of key employee List the organization s five urrent highest ompensate employees (other than an offier, iretor, trustee, or key employee) who reeive reportale ompensation (Box of Form W- an/or Box 7 of Form -MISC) of more than $, from the organization an any relate organizations List all of the organization s former offiers, key employees, an highest ompensate employees who reeive more than $, of reportale ompensation from the organization an any relate organizations List all of the organization s former iretors or trustees that reeive, in the apaity as a former iretor or trustee of the organization, more than $, of reportale ompensation from the organization an any relate organizations List persons in the following orer: iniviual trustees or iretors; institutional trustees; offiers; key employees; highest ompensate employees; an former suh persons Chek this ox if neither the organization nor any relate organization ompensate any urrent offier, iretor, or trustee (C) Former Highest ompensate employee Key employee Average hours per week (esrie hours for relate organizations in Sheule O) Offier Name an Title Position (o not hek more than one ox, unless person is oth an offier an a iretor/trustee) Institutional trustee (B) Iniviual trustee or iretor (A) (D) (E) (F) Reportale Reportale ompensation ompensation from from relate the organizations organization (W-/-MISC) (W-/-MISC) Estimate amount of other ompensation from the organization an relate organizations () Rohelle Upright-Sexton, Boar Presient () Melissa Velez, Boar Vie-Presient () Niko Triggs, Boar memer at large-fisal YE urrently Treasurer/Seretary () Deanna Burton, Boar memer at large () Patty De Bruin, Boar memer at large () Sharon Fliess, Boar memer at large (7) Marella Ganolfo, Boar memer at large () Gwenolyn MGee, Boar memer at large () Joi Shmit, Boar memer at large () Kerri Tyler, Boar memer at large () Jennifer MDaniel Wolfe, Boar memer at large () Janis Serak, Exeutive Co-Diretor 7 () Charlotte Prie, Exeutive Co-Diretor () Form ()

8 Page Form () Part VII Setion A Offiers, Diretors, Trustees, Key Employees, an Highest Compensate Employees (ontinue) (C) Former Highest ompensate employee Key employee Offier Institutional trustee (B) Average hours per week (esrie hours for relate organizations in Sheule O) Iniviual trustee or iretor (A) Name an title Position (o not hek more than one ox, unless person is oth an offier an a iretor/trustee) (D) (E) (F) Reportale Reportale ompensation ompensation from from relate the organizations organization (W-/-MISC) (W-/-MISC) Estimate amount of other ompensation from the organization an relate organizations () () (7) () () () () () () () () Su-total Total from ontinuation sheets to Part VII, Setion A Total (a lines an ) Total numer of iniviuals (inluing ut not limite to those liste aove) who reeive more than $, of reportale ompensation from the organization Di the organization list any former offier, iretor, or trustee, key employee, or highest ompensate employee on line a? If, omplete Sheule J for suh iniviual For any iniviual liste on line a, is the sum of reportale ompensation an other ompensation from the organization an relate organizations greater than $,? If, omplete Sheule J for suh iniviual Di any person liste on line a reeive or arue ompensation from any unrelate organization or iniviual for servies renere to the organization? If, omplete Sheule J for suh person Setion B Inepenent Contrators Complete this tale for your five highest ompensate inepenent ontrators that reeive more than $, of ompensation from the organization Report ompensation for the alenar year ening with or within the organization's tax year (A) Name an usiness aress (B) Desription of servies (C) Compensation Total numer of inepenent ontrators (inluing ut not limite to those liste aove) who reeive more than $, of ompensation from the organization Form ()

9 Page Form () Part VIII Statement of Revenue Program Servie Revenue Contriutions, Gifts, Grants an Other Similar Amounts (A) Total revenue a e f a e Feerate ampaigns Memership ues Funraising events Relate organizations Government grants (ontriutions) All other ontriutions, gifts, grants, an similar amounts not inlue aove (C) Unrelate usiness revenue (D) Revenue exlue from tax uner setions,, or f g nash ontriutions inlue in lines a-f: $ h Total A lines a f Business Coe a e f All other program servie revenue g Total A lines a f Investment inome (inluing iviens, interest, an other similar amounts) Inome from investment of tax-exempt on proees Royalties (i) Real Gross rents Less: rental expenses Rental inome or (loss) Net rental inome or (loss) (i) Seurities Gross amount from sales of assets other than inventory Less: ost or other asis an sales expenses Gain or (loss) Net gain or (loss) a a a 7 7 (ii) Personal a 7a Other Revenue (B) Relate or exempt funtion revenue Gross inome from funraising events (not inluing $ of ontriutions reporte on line ) See Part IV, line a Less: iret expenses Net inome or (loss) from funraising events Gross inome from gaming ativities See Part IV, line a Less: iret expenses Net inome or (loss) from gaming ativities Gross sales of inventory, less returns an allowanes a Less: ost of goos sol Net inome or (loss) from sales of inventory Business Coe Misellaneous Revenue a Loss on isposal of assets All other revenue e Total A lines a Total revenue See instrutions (ii) Other Form ()

10 Page Form () Part IX Statement of Funtional Expenses Setion ()() an ()() organizations must omplete all olumns All other organizations must omplete olumn (A) ut are not require to omplete olumns (B), (C), an (D) Chek if Sheule O ontains a response to any question in this Part IX Do not inlue amounts reporte on lines, 7,,, an of Part VIII (B) Program servie expenses (C) Management an general expenses (D) Funraising expenses Grants an other assistane to governments an organizations in the Unite States See Part IV, line Grants an other assistane to iniviuals in the Unite States See Part IV, line Grants an other assistane to governments, organizations, an iniviuals outsie the Unite States See Part IV, lines an Benefits pai to or for memers Compensation of urrent offiers, iretors, trustees, an key employees Compensation not inlue aove, to isqualifie persons (as efine uner setion (f)()) an persons esrie in setion ()()(B) 7 Other salaries an wages Pension plan aruals an ontriutions (inlue setion (k) an () employer ontriutions) Other employee enefits Payroll taxes Fees for servies (non-employees): a Management Legal Aounting Loying e Professional funraising servies See Part IV, line 7 f Investment management fees g Other Avertising an promotion Offie expenses Information tehnology Royalties Oupany 7 Travel Payments of travel or entertainment expenses for any feeral, state, or loal puli offiials (A) Total expenses Conferenes, onventions, an meetings Interest Payments to affiliates Depreiation, epletion, an amortization Insurane Other expenses Itemize expenses not overe aove (List misellaneous expenses in line e If line e amount exees % of line, olumn (A) amount, list line e expenses on Sheule O) a e All other expenses Total funtional expenses A lines through e Joint osts Complete this line only if the organization reporte in olumn (B) joint osts from a omine euational ampaign an funraising soliitation Chek here if following SOP - (ASC -7) Form ()

11 Page Form () Part X Balane Sheet Net Assets or Fun Balanes Liailities Assets (A) Beginning of year Cash non-interest-earing Savings an temporary ash investments Pleges an grants reeivale, net Aounts reeivale, net Reeivales from urrent an former offiers, iretors, trustees, key employees, an highest ompensate employees Complete Part II of Sheule L Reeivales from other isqualifie persons (as efine uner setion (f)()), persons esrie in setion ()()(B), an ontriuting employers an sponsoring organizations of setion ()() voluntary employees' enefiiary organizations (see instrutions) 7 a 7 tes an loans reeivale, net Inventories for sale or use Prepai expenses an eferre harges Lan, uilings, an equipment: ost or other asis Complete Part VI of Sheule D 7 a Less: aumulate epreiation Investments pulily trae seurities Investments other seurities See Part IV, line Investments program-relate See Part IV, line Intangile assets Other assets See Part IV, line Total assets A lines through (must equal line ) Aounts payale an arue expenses Grants payale Deferre revenue Tax-exempt on liailities Esrow or ustoial aount liaility Complete Part IV of Sheule D Payales to urrent an former offiers, iretors, trustees, key employees, highest ompensate employees, an isqualifie persons Complete Part II of Sheule L Seure mortgages an notes payale to unrelate thir parties Unseure notes an loans payale to unrelate thir parties Other liailities (inluing feeral inome tax, payales to relate thir parties, an other liailities not inlue on lines 7-) Complete Part X of Sheule D Total liailities A lines 7 through Organizations that follow SFAS 7, hek here lines 7 through, an lines an 7 Unrestrite net assets Temporarily restrite net assets Permanently restrite net assets Organizations that o not follow SFAS 7, hek here omplete lines through Capital stok or trust prinipal, or urrent funs Pai-in or apital surplus, or lan, uiling, or equipment fun Retaine earnings, enowment, aumulate inome, or other funs Total net assets or fun alanes Total liailities an net assets/fun alanes an omplete an (B) En of year Form ()

12 Page Form () Part XI Reoniliation of Net Assets Chek if Sheule O ontains a response to any question in this Part XI Total revenue (must equal Part VIII, olumn (A), line ) Total expenses (must equal Part IX, olumn (A), line ) Revenue less expenses Sutrat line from line Net assets or fun alanes at eginning of year (must equal Part X, line, olumn (A)) Other hanges in net assets or fun alanes (explain in Sheule O) Net assets or fun alanes at en of year Comine lines,, an (must equal Part X, line, olumn (B)) Part XII Finanial Statements an Reporting Chek if Sheule O ontains a response to any question in this Part XII Aounting metho use to prepare the Form : Cash Arual Other If the organization hange its metho of aounting from a prior year or heke Other, explain in Sheule O a Were the organization s finanial statements ompile or reviewe y an inepenent aountant? Were the organization s finanial statements auite y an inepenent aountant? If to line a or, oes the organization have a ommittee that assumes responsiility for oversight of the auit, review, or ompilation of its finanial statements an seletion of an inepenent aountant? If the organization hange either its oversight proess or seletion proess uring the tax year, explain in Sheule O If to line a or, hek a ox elow to iniate whether the finanial statements for the year were issue on a separate asis, onsoliate asis, or oth: Separate asis Consoliate asis Both onsoliate an separate asis As a result of a feeral awar, was the organization require to unergo an auit or auits as set forth in the Single Auit At an OMB Cirular A-? If, i the organization unergo the require auit or auits? If the organization i not unergo the require auit or auits, explain why in Sheule O an esrie any steps taken to unergo suh auits a a a Form ()