Illinois Charitable Organization Annual Report Form (Page 2 of 2) in pdf

IF THE ANSWER TO ANY OF THE FOLLOWING IS YES, ATTACH A DETAILED EXPLANATION:

YES

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WAS THE ORGANIZATION THE SUBJECT OF ANY COURT ACTION, FINE, PENALTY OR JUDGMENT?

HAS THE ORGANIZATION OR A CURRENT DIRECTOR, TRUSTEE, OFFICER OR EMPLOYEE THEREOF,

EVER BEEN CONVICTED BY ANY COURT OF ANY MISDEMEANOR INVOLVING THE MISUSE OR

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MISAPPROPRIATION OF FUNDS OR ANY FELONY?

DID THE ORGANIZATION MAKE A GRANT AWARD OR CONTRIBUTION TO ANY ORGANIZATION IN WHICH

ANY OF ITS OFFICERS, DIRECTORS OR TRUSTEES OWNS AN INTEREST; OR WAS IT A PARTY TO ANY TRANSACTION

IN WHICH ANY OF ITS OFFICERS, DIRECTORS OR TRUSTEES HAS A MATERIAL FINANCIAL INTEREST; OR DID

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ANY OFFICER, DIRECTOR OR TRUSTEE RECEIVE ANYTHING OF VALUE NOT REPORTED AS COMPENSATION?

HAS THE ORGANIZATION INVESTED IN ANY CORPORATE STOCK IN WHICH ANY OFFICER, DIRECTOR OR

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TRUSTEE OWNS MORE THAN 10% OF THE OUTSTANDING SHARES?

IS ANY PROPERTY OF THE ORGANIZATION HELD IN THE NAME OF OR COMMINGLED WITH THE

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PROPERTY OF ANY OTHER PERSON OR ORGANIZATION?

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DID THE ORGANIZATION USE THE SERVICES OF A PROFESSIONAL FUNDRAISER? (ATTACH FORM IFC)

DID THE ORGANIZATION ALLOCATE THE COST OF ANY SOLICITATION, MAILING, ADVERTISEMENT OR

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LITERATURE COSTS BETWEEN PROGRAM SERVICE AND FUNDRAISING EXPENSES?

IF "YES", ENTER (i) THE AGGREGATE AMOUNT OF THESE JOINT COSTS $

; (ii) THE AMOUNT

ALLOCATED TO PROGRAM SERVICES $

; (iii) THE AMOUNT ALLOCATED TO MANAGEMENT

AND GENERAL $

; AND (iv) THE AMOUNT ALLOCATED TO FUNDRAISING $

DID THE ORGANIZATION EXPEND ITS RESTRICTED FUNDS FOR PURPOSES OTHER THAN RESTRICTED

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PURPOSES?

HAS THE ORGANIZATION EVER BEEN REFUSED REGISTRATION OR HAD ITS REGISTRATION OR TAX EXEMPTION

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SUSPENDED OR REVOKED BY ANY GOVERNMENTAL AGENCY?

10.

WAS THERE OR DO YOU HAVE ANY KNOWLEDGE OF ANY KICKBACK, BRIBE, OR ANY THEFT, DEFALCATION

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MISAPPROPRIATION, COMMINGLING OR MISUSE OF ORGANIZATIONAL FUNDS?

10.

11.

LIST THE NAME AND ADDRESS OF THE FINANCIAL INSTITUTIONS WHERE THE ORGANIZATION MAINTAINS ITS

THREE LARGEST ACCOUNTS:

BANK OF AMERICA, 135 S LASALLE ST., CHICAGO, IL 60603; HARRIS BANK, 111 W MONROE ST.

CHICAGO, IL 60603; CHASE BANK, 10 SOUTH DEARBORN, CHICAGO, IL 60602

12.

NAME AND TELEPHONE NUMBER OF CONTACT PERSON:

LOWELL B. RAVEN, CPA 773-388-8794

ALL ATTACHMENTS MUST ACCOMPANY THIS REPORT - SEE INSTRUCTIONS

UNDER PENALTY OF PERJURY, I (WE) THE UNDERSIGNED DECLARE AND CERTIFY THAT I (WE) HAVE EXAMINED THIS ANNUAL REPORT

AND THE ATTACHED DOCUMENTS, INCLUDING ALL THE SCHEDULES AND STATEMENTS AND THE FACTS THEREIN STATED ARE

TRUE AND COMPLETE AND FILED WITH THE ILLINOIS ATTORNEY GENERAL FOR THE PURPOSE OF HAVING THE PEOPLE OF THE

STATE OF ILLINOIS RELY THEREUPON. I HEREBY FURTHER AUTHORIZE AND AGREE TO SUBMIT MYSELF AND THE REGISTRANT

HEREBY TO THE JURISDICTION OF THE STATE OF ILLINOIS.

PRESIDENT or TRUSTEE

SIGNATURE

DATE

(PRINT NAME)

BE SURE TO INCLUDE ALL FEES DUE:

1.) REPORTS ARE DUE WITHIN SIX

MONTHS OF YOUR FISCAL YEAR END.

2.) FOR FEES DUE SEE INSTRUCTIONS.

TREASURER or TRUSTEE

SIGNATURE

DATE

(PRINT NAME)

3.) REPORTS THAT ARE LATE OR

INCOMPLETE ARE SUBJECT TO A

5/2/13

GERALYN HURD

$100.00 PENALTY.

PREPARER

SIGNATURE

DATE

(PRINT NAME)

1J1515 1.000

Illinois Charitable Organization Annual Report Form Page 2

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