Form 990-Ez - Return Of Organization Exempt From Income Tax - 2012 Page 12
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15Schedule G (Form 990 or 990-EZ) 2012
Does the organization operate gaming activities with nonmembers?
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. Yes r- No
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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?
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. Yes r- No
13
Indicate the percentage of gaming activity operated in
a
The organization ' s facility
13a
b
An outside facility
13b
14
Enter the name and address of the person who prepares the organization's gaming / special events books and records
Name
Address
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue?
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r- Yes r- No
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 of the third party
Name '
Address '
---------------- ------------------------------ ------------------------------ ------------------------------------------------------------ ------------------------------ -
16
Gaming manager information
Name llik^
------------ ----------------------- ---------------------- ----------------------- ----------------------- ----------------------- ---------------------- -
Gaming manager compensation
$ _ --------------------------------------------
Description of services provided
---------- ------------------ ------------------ ------------------ ------------------- ------------------ ------------------ ------------------ ----------
r- Director/ officer
Employee
Independent contractor
17
Mandatory distributions
a
Is the organization required understate law to make charitable distributions from the gaming proceeds to
retain the state gaming license?
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r-Yes
r-No
b
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
$
Supplemental Information . Complete this part to provide the explanations required by Part I, line 2b,
columns ( iii) and (v ), and Part III, lines 9 , 9b, 10b , 15b, 15c, 16, and 17b , as applicable. Also complete this
part to provide any additional information ( see instructions).
I
Identifier
Return Reference
I
Explanation
Page 3 11
Schedule G (Form 990 or 990-EZ) 2012
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