Schedule G (Form 990 Or 990-Ez) - Supplemental Information Regarding Fundraising Or Gaming Activities - 2015 Page 3

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Schedule G (Form 990 or 990-EZ) 2015
Page
11
Yes
No
Does the organization conduct 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 conducted 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
▶
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
▶
amount of gaming revenue retained by the third party
$
▶
c If “Yes,” enter name and address of the third party:
Name
▶
Address
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16
Gaming manager information:
Name
▶
Gaming manager compensation
$
▶
Description of services provided
▶
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. 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 provide any additional information (see
instructions).
Schedule G (Form 990 or 990-EZ) 2015

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