Form Ag990-Il - Illinois Charitable Organization Annual Report (Page 2 of 2) in pdf

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

YES NO

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 MIDSDEMEANOR INVOLVING THE MISUSE OR

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

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

TRUSTEE OWNS MORE THAN 10% OF THE OUTSTANDING SHARES?

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

PROPERTY OF ANY OTHER PERSON OR ORGANIZATION?

( ATTACH FORM IFC )

DID THE ORGANIZATION USE THE SERVICES OF A PROFESSIONAL FUNDRAISER?

7a. DID THE ORGANIZATION ALLOCATE THE COST OF ANY SOLICITATION, MAILING, ADVERTISEMENT OR

LITERATURE COSTS BETWEEN PROGRAM SERVICE AND FUNDRAISING EXPENSES?

7b. 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

PURPOSES?

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

SUSPENDED OR REVOKED BY ANY GOVERNMENTAL AGENCY?

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

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:

12. NAME AND TELEPHONE NUMBER OF CONTACT PERSON:

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

$100.00 PENALTY.

PREPARER

(PRINT NAME)

SIGNATURE

DATE

Form Ag990-Il - Illinois Charitable Organization Annual Report Page 2

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