an example
form
imp.// www.ns.guv/puD/irs~par/Tyyu. par
990
Open to Public Inspection
The organization may have to use a copy of this return to satisfy state reporting requirements.
For the 2012 calendar year, or tax year beginning
_,_2_Q 12, and ending
B Check if applicable C Name of organization Doing Business As CD Address change Numoer and street (or P.O. box if mail :s not delivered to street address) . Name change
20 D Employer Identification number
Room/suite
E Telephone number
City, town or post office, state, and ZIP code
f_j Terminated
G Gross receipts $
: j Amended return Application pending f Name and address ol principal officer: I J
jax-exempt status:______LJ501jgg| ....... _D.APJM.L Wobslto: *
K
Form of organization:!
Activities & Governance
12
Under section 501 (c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)
of tlie Treasury I Department Internal Revenue Service
A
OMB No, 1545-0047
Return of Organization Exempt From Income Tax
Corporation | j Trust
[ J Association :..
H(a) is this a group return tor affiliates? ! 1 Yes I_J No H(b) Are ail affiliates included? ! ] Yes IJ No If "No," attach a list (see instructions) H(c) Croup oxompllon number > L Year ol formation:
M State of legal domicile:
1
Summary Briefly describe the organization's mission or most significant activities:
2 3 4 5 6 7a b
Check this box^- i if the organization discontinued its operations or disposed of more than 25 % o f its net assets. . . . . Number of voting members of the governing body (Part VI, line 1a) . . . . 3 Number of indepe ndent voting members of the governing body (Part VI, line 1 b) . . . . 4 Total number of in dividuals employed in calendar year 2012 (Part V, line 2a) 5 Total number of v slunteers (estimate if necessary) 6 __.™..^__ Total unrelated bu siness revenue from Part VIII, column (C), line 12 7a Net unrelated bus ness taxable income from Form 990-T, line 34 7tT
Revenue
Prior Year
"
8 9 10 11 12 13 14 15 16a b 17 18 19
• Contributions and grants (Part VIII line 1 h) Program service r avenue (Part VIII, line 2q) Investment incom 9 (Part VIII, column (A), lines 3, 4, and 7d) Other revenue (Pa rt VIM. column (A), lines 5, 6d, 8c,9c, 10c, and 11e) . . . | Total revenue— ad d lines 8 through 11 (must equal Part VIII, column (A), line 12) i Grants and similar amounts paid (Part IX, column (A), lines 1-3) Benefits paid to o for members (Part IX, column (A), line 4) Salaries, other con pensation, employee benefits (Part IX, column (A), lines 5-10) Professional fundr aising fees (Part IX, column (A), line 11 e) Total fundraising e xpenses (Part IX, column (D), line 25) > Other expenses (F art IX, column (A), lines 11a-11d, 11f-24e) Total expenses. A 3d lines 1 3-1 7 (must equal Part IX, column (A), line 25} Revenue less exp snses. Subtract line 18 from line 12
20 21 22
Total assets (Part X, line 16) Total liabilities (Pa rt X, line 26} Net assets or fund balances. Subtract line 21 from line 20 Signature Block
Current Year — • •—
.
! Beginning of Current Year
°8
_„.
End ot Year
, | |
Under ponallins of perjury. I rtfx:laro that I havo oxaminort this rot urn. including accompanying sctiortulos and staiemnnts. arid to the host ot my Knowledge and txiiifif, it is iru(!, corrtx;!. and uornplola Uoclarallon ol prepare;! (other Ihan ofllcor) la basod on all Information ul which proparcr IIFIS any knowkxJgu.
i
Sign Here *
Paid Preparer bse Only
i Signature ot officer
Date
Type or print name and title Print/Type preparer's name
Firm's name
j Prcparor's signature
>•
Finn's address > May the IRS discuss this return with the preparer shown above? (see instructions) For Paperwork Reduction Act Notice, see the separate instructions.
of 12
I Daie
] Cneck Q l7fPTIN | self-employed i i Firm's EIN >
[ Phone no. L Yes [ | No Cat. No. 112S2Y
Form 990 (2012)
3/27/2013 4:50 PM
imp.// www.ns.guv/puD/irs~par/Tyyu. par
990
Open to Public Inspection
The organization may have to use a copy of this return to satisfy state reporting requirements.
For the 2012 calendar year, or tax year beginning
_,_2_Q 12, and ending
B Check if applicable C Name of organization Doing Business As CD Address change Numoer and street (or P.O. box if mail :s not delivered to street address) . Name change
20 D Employer Identification number
Room/suite
E Telephone number
City, town or post office, state, and ZIP code
f_j Terminated
G Gross receipts $
: j Amended return Application pending f Name and address ol principal officer: I J
jax-exempt status:______LJ501jgg| ....... _D.APJM.L Wobslto: *
K
Form of organization:!
Activities & Governance
12
Under section 501 (c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)
of tlie Treasury I Department Internal Revenue Service
A
OMB No, 1545-0047
Return of Organization Exempt From Income Tax
Corporation | j Trust
[ J Association :..
H(a) is this a group return tor affiliates? ! 1 Yes I_J No H(b) Are ail affiliates included? ! ] Yes IJ No If "No," attach a list (see instructions) H(c) Croup oxompllon number > L Year ol formation:
M State of legal domicile:
1
Summary Briefly describe the organization's mission or most significant activities:
2 3 4 5 6 7a b
Check this box^- i if the organization discontinued its operations or disposed of more than 25 % o f its net assets. . . . . Number of voting members of the governing body (Part VI, line 1a) . . . . 3 Number of indepe ndent voting members of the governing body (Part VI, line 1 b) . . . . 4 Total number of in dividuals employed in calendar year 2012 (Part V, line 2a) 5 Total number of v slunteers (estimate if necessary) 6 __.™..^__ Total unrelated bu siness revenue from Part VIII, column (C), line 12 7a Net unrelated bus ness taxable income from Form 990-T, line 34 7tT
Revenue
Prior Year
"
8 9 10 11 12 13 14 15 16a b 17 18 19
• Contributions and grants (Part VIII line 1 h) Program service r avenue (Part VIII, line 2q) Investment incom 9 (Part VIII, column (A), lines 3, 4, and 7d) Other revenue (Pa rt VIM. column (A), lines 5, 6d, 8c,9c, 10c, and 11e) . . . | Total revenue— ad d lines 8 through 11 (must equal Part VIII, column (A), line 12) i Grants and similar amounts paid (Part IX, column (A), lines 1-3) Benefits paid to o for members (Part IX, column (A), line 4) Salaries, other con pensation, employee benefits (Part IX, column (A), lines 5-10) Professional fundr aising fees (Part IX, column (A), line 11 e) Total fundraising e xpenses (Part IX, column (D), line 25) > Other expenses (F art IX, column (A), lines 11a-11d, 11f-24e) Total expenses. A 3d lines 1 3-1 7 (must equal Part IX, column (A), line 25} Revenue less exp snses. Subtract line 18 from line 12
20 21 22
Total assets (Part X, line 16) Total liabilities (Pa rt X, line 26} Net assets or fund balances. Subtract line 21 from line 20 Signature Block
Current Year — • •—
.
! Beginning of Current Year
°8
_„.
End ot Year
, | |
Under ponallins of perjury. I rtfx:laro that I havo oxaminort this rot urn. including accompanying sctiortulos and staiemnnts. arid to the host ot my Knowledge and txiiifif, it is iru(!, corrtx;!. and uornplola Uoclarallon ol prepare;! (other Ihan ofllcor) la basod on all Information ul which proparcr IIFIS any knowkxJgu.
i
Sign Here *
Paid Preparer bse Only
i Signature ot officer
Date
Type or print name and title Print/Type preparer's name
Firm's name
j Prcparor's signature
>•
Finn's address > May the IRS discuss this return with the preparer shown above? (see instructions) For Paperwork Reduction Act Notice, see the separate instructions.
of 12
I Daie
] Cneck Q l7fPTIN | self-employed i i Firm's EIN >
[ Phone no. L Yes [ | No Cat. No. 112S2Y
Form 990 (2012)
3/27/2013 4:50 PM
