Form 990-Ez - Short Form Return Of Organization Exempt From Income Tax - 2012 Page 3

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3
Form 990-EZ (2012)
Page
Part V
Other Information (Note the Schedule A and personal benefit contract statement requirements in the
instructions for Part V) Check if the organization used Schedule O to respond to any question in this Part V
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Yes No
33
Did the organization engage in any significant activity not previously reported to the IRS? If “Yes,” provide a
detailed description of each activity in Schedule O .
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33
34
Were any significant changes made to the organizing or governing documents? If “Yes,” attach a conformed
copy of the amended documents if they reflect a change to the organization's name. Otherwise, explain the
change on Schedule O (see instructions)
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34
35 a Did the organization have unrelated business gross income of $1,000 or more during the year from business
activities (such as those reported on lines 2, 6a, and 7a, among others)? .
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35a
b If “Yes,” to line 35a, has the organization filed a Form 990-T for the year? If “No,” provide an explanation in Schedule O
35b
c Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice,
reporting, and proxy tax requirements during the year? If “Yes,” complete Schedule C, Part III .
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35c
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets
during the year? If “Yes,” complete applicable parts of Schedule N
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36
37 a Enter amount of political expenditures, direct or indirect, as described in the instructions
37a
b Did the organization file Form 1120-POL for this year? .
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37b
38a Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?
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38a
b If “Yes,” complete Schedule L, Part II and enter the total amount involved
38b
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39
Section 501(c)(7) organizations. Enter:
a Initiation fees and capital contributions included on line 9 .
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39a
b Gross receipts, included on line 9, for public use of club facilities
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39b
40 a Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
section 4911
; section 4912
; section 4955
b Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefit
transaction during the year, or did it engage in an excess benefit transaction in a prior year that has not been
reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I .
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40b
c Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on
organization managers or disqualified persons during the year under sections 4912,
4955, and 4958 .
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Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c
d
reimbursed by the organization
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e All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter
transaction? If “Yes,” complete Form 8886-T .
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40e
List the states with which a copy of this return is filed
41
42a The organization's books are in care of
Telephone no.
Located at
ZIP + 4
b At any time during the calendar year, did the organization have an interest in or a signature or other authority over
Yes No
a financial account in a foreign country (such as a bank account, securities account, or other financial account)?
42b
If “Yes,” enter the name of the foreign country:
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank
and Financial Accounts.
c At any time during the calendar year, did the organization maintain an office outside the U.S.? .
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42c
If “Yes,” enter the name of the foreign country:
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Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041—Check here
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43
and enter the amount of tax-exempt interest received or accrued during the tax year .
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Yes No
44 a Did the organization maintain any donor advised funds during the year? If “Yes,” Form 990 must be
completed instead of Form 990-EZ .
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44a
b Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be
completed instead of Form 990-EZ
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44b
c Did the organization receive any payments for indoor tanning services during the year? .
44c
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d If "Yes" to line 44c, has the organization filed a Form 720 to report these payments? If "No," provide an
explanation in Schedule O
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44d
45
a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
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45a
45 b Did the organization receive any payment from or engage in any transaction with a controlled entity within the
meaning of section 512(b)(13)? If “Yes,” Form 990 and Schedule R may need to be completed instead of
Form 990-EZ (see instructions) .
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45b
990-EZ
Form
(2012)

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