Schedule G (Form 990 Or 990-Ez) - Supplemental Information Regarding Fundraising Or Gaming Activities - 2012 Page 3

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Schedule G (Form 990 or 990-EZ) 2012
Page
11
Yes
No
Does the organization operate gaming activities with nonmembers?
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12
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
No
13
Indicate the percentage of gaming activity operated in:
%
a The organization’s facility
13a
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b An outside facility .
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13b
14
Enter the name and address of the person who prepares the organization’s gaming/special events books and
records:
Name
▶
Address
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15a Does the organization have a contract with a third party from whom the organization receives gaming
revenue? .
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Yes
No
b If “Yes,” enter the amount of gaming revenue received by the organization
$
and the
▶
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amount of gaming revenue retained by the third party
$
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c If “Yes,” enter name and address of the third party:
Name
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Address
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16
Gaming manager information:
Name
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Gaming manager compensation
$
▶
Description of services provided
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Director/officer
Employee
Independent contractor
17
Mandatory distributions:
a Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license?
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Yes
No
b Enter the amount of distributions required under state law to be distributed to other exempt organizations or
spent in the organization’s own exempt activities during the tax year
$
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Part IV
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).
Schedule G (Form 990 or 990-EZ) 2012

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