Mid Valley Mentors 2012 Charity Report
-
Upload
statesman-journal -
Category
Documents
-
view
220 -
download
0
Transcript of Mid Valley Mentors 2012 Charity Report
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
1/21
F orm
CT-12
F o r
O r e g o n C h a r i t i e s
Charitable
Activit ies Section
Oregon Department of Just ice
1515 SW 5 th Avenue , Su i te 410
P or t l and , OR 9 7201 -545 1
Em a i l : cha r i tab l e . ac t i v i t i e s@d o j . s ta te . o r . us
Webs i te : h t tp : / / vww. d o j . s ta te . o r . us
VOICE ( 9 7 1 ) 6 7 3 - 1 8 8 0
TT Y
( 800 ) 735 -29 00
FAX
( 9 7 1 ) 6 7 3 - 1 8 8 2
F or Accou n t i ng P e r i od s Beg inn in
2012
Section I. Gene ralInformation
1.
#38039
iVIlDV A L L E Y M E N T O R S
3030 C E N T E R S T R E E T N E
S A L E M , O R 9 7 3 0 1
(503)409-6533
07/01/12 6 /30/13
C r o s sThro ugh Incorrect I tems and C orrect Here:
(See instruct ions for change of name or account ing per iod . )
Registration # :
Organization N a m e :
A d d r e s s :
Ci ty, S ta te , Z ip :
P hone :
Em a i l :
Period Beg inn ing :
Fax:
Period End ing :
' ^ ^ O ^ ^ ^ ' Q S m e n d e
^ Repor t
/ _
Did
a cer t i f ied publ ic accountant aud i t your f inancia l records? - I f yes, a t tach a copy of the aud i tor ' s repor t , f inancia i s ta tements,
accompanying no tes , sched u les , o r o the r d ocum en ts supp lem en t i ng the repo r t o r f i nanc ia l s ta tem en ts .
Is the o rgan i za t i on a pa r ty to a con t rac t i n vo l v i ng pe rson - to -pe rso n , ad ve r t i s i ng , vend ing m a ch ine o r te l ephone fund - ra i s i ng In
Oregon?
I f yes , w r i te the nam e o f the fund - ra i s i ng f i rm (s ) who cond uc ts the cam pa lgn (s ) :
H as the o rgan i za t i on o r any o f i t s o f f i ce rs , d i r ec to rs , tr us tees , o r key em p loy ees eve r s i gned a vo l un ta ry ag reem en t w i th a ny
govemment
agency, such as a sta te a t torney genera l , secre tary of s ta te , or loca l d is t r ic t a t torney, or been a par ty to lega l act ion
in any cou r t r ega rd ing cha r i tab l e so l i c i ta t ion , ad m in i s t ra t i on , m ana gem e n t , o r f i d uc ia ry p rac t i ces ? I f yes , a t tach exp lana t i on o f
each such ag reem en t o r ac t i on . See Ins t ruc t i ons .
During th is repor t ing per iod , d id the organ iza t ion amend i ts ar t ic les of incorpora t ion , bylaws, or t rust documents, OR d id the
organization rece ive a deter minat ion le t te r f rom the In terna l Reven ue Serv ice re la t ing to Its tax-e xem pt sta tus? I f yes, a t tach a
copy o f the am e nd ed d ocum en t o r l e t te r.
Is the organ iz a t ion c easing o pera t io ns an d is th is the f ina l repor t? ( I f yes , see instruc t ions on how to c lose your reg istra t ion . )
Provide
contact in format ion for the person responsib le for re ta in ing the organ iza t ion 's records.
ZlYes
m
Yes
Zl
2
Y e s 0
m Yes
Yes
Zl
Z
Name
Position
Phone
Mailing Ad d ress & Em a i l Ad d ress
SARAH C A V A Z O S
EXECUTIVE
DIRECTOR
503-409-6533
SAME A S A B O V E
List
o f Off ice rs, Di rectors, Trus tees an d Key Em ploy ees - L is t each pe rson wh o he ld one of thes e posi t ions a t any t ime dur ing the year eve n i f they
not r ece i ve com pens a t i on . A t tach ad d i t i ona l shee ts if necessa ry . I f an a t tached IRS fo rm i nc l ud es subs tan t ia l l y the sam e com p ensa t i on i n fo rm a t i o
the ph rase "Se e IRS F o rm " m ay be en te red i n li eu o f com p le t i ng tha t sec t i on . (O regon l aw requ i res a m in im um o f th ree d i rec to rs .)
(A )
Nam e , m a i l i ng ad d ress , d ay t im e phone num be r
and em a i l ad d ress
(B) Tit le &
average week l y
hou rs d evo ted to
position
(C)
Compensation
(enter $0 i f
position unpa id )
N a m e :
A d d r e s s :
P hone :
Em a i l :
SE E A T T A C H M E N T
L )
Nam e :
A d d r e s s :
P hone :
Emai l :
( )
Nam e :
A d d r e s s :
P hone :
Emai l :
( J
F o r m C o n t i n u e d o n
R e v e r s e S i d e
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
2/21
Section II. F ee Ca lculation
10.
11.
12.
13.
14.
15.
16.
17.
Total R e v e n u e
( F r o m
L i ne
12 (cun-ent yea r ) on Form 990;
L i ne
9 on Form 990-EZ; Par t I ,
L i ne
1 2 a o n F o r m 9 9 0 - P F ;
L i ne
9 on Forni 1041
o r F o r m
1041-A;
or see page 3 o f
ttie
ins t ruc t ions If no federa l tax re turn was pre pared . A t tac h exp lana t ion i f To ta l
R e v e n u e
Is $0 . )
$240,530.00
Revenue Fee
( S e e
char t
below. Minimum
fee is
$10,
even i f
total
revenue is a nega t ive amount )
$7
Amount
o n L i n e 9
R e v e n u e
F e e
$0
$24,999 $10
$25,000 $49,999
$25
$50,000 $99,999
$45
$100,000
$249,999
$75
$250,000 $499,999
$100
$500,000 $749,999
$135
$750,000 $999,999
$170
$1,000,000 or
more
$200
Net Asse ts o r F und Ba lances a t End o f the Repor t i ng P e r i od . . . .
( F r o m L i n e 22 (end o f yea r ) on Form 990, L i ne 21 on
F o m i
990-EZ, o r Pa r t I I I , Line
6 on F orm 99 0-P F; o r see page 3 o f CT-1 2 ins t ruc tions to ca lcu la te . )
Net F i xed Asse ts Used to Cond uc t Cha r i tab l e Ac t i v i t i e s
(Genera l ly ,
from Part X,
L i ne 10c
o n F o r m 9 9 0 ,
L i ne
2 3 B o n
F o m i
990-EZ or Par t
II,
L i ne 14b on Form 9 90-P F; o r se e page 4 o f CT-1 2 ins tn jc t ions to ca lcu la te . S ee
i nst ruct i ons
i f o rganiza t ion ow ns income-produc ing. )
Amount Sub jec t to Ne t Asse ts o r F und Ba lances F ee
( L i ne
11
m i n u s
L i ne
12. If
L i ne
11
m i n u s
L i n e
12 is
l es s
than $50,000,
write
$0.)
11.
12.
$43,232.00
13.
$0.00
Net Asse ts o r F und Ba lances F ee
( L i ne
13 mult iplied by
0001,
If the fee isl es s than $5, enter 3
Not
t o e x c e e d $ 1 ,0 0 0 . R o u n d
c e n t s
to the neares t whole do l la r . )
Ar e you f i l ing th is repor t la te? Yes No . ,
(If
yes , the la te fee is a min imum of $20, You may ow e more depen ding on how la te the repor t
is.
Se e Ins t ruc t ion
15
for addit ional information or contact the
C h a r i t a b l e
Ac t iv i t ies Sec t ion a t (971) 673-1880 to obtain late fee amount . )
Total A m o u n t D u e
(Add L i n e s
10,14, an d
15 .
Make
c h e c k
payable to the Oregon Depar tment o f
Jus t ic e . )
14.
$
15.
$2
16.
$9
Attach a copy of the organ iza t ion 's federa l 990 or o ther re turn and a l l suppor t ing schedu les and a t tachments tha t were f i led wi th the IRS wi th the
exception tha t Form 990 & 990 EZ f i le rs do not need to a t tach a copy of the i r Sched u le B. A lso , if the organ iz a t ion d id not
file
wi th the IRS or f i led a
990 -N , bu t had To ta l R evenue o f $25 ,000 o r m ore , o r Ne t Asse ts o r F und Ba lances o f $50 ,000 o r m ore , see the ins t ruc t i ons as the o rgan i za t i on m a
be
r equ i red to com p le te ce r ta i n IRS F o rm s fo r O rego n pu rpose s on l y . I f the a t tached re tu m was no t f i l ed w i th the IRS , then m a rk any such re tu rn a
"For Orego n Purp ose s Only. " I f your organ iz a t ion f i les IRS Form 990-N (e-Pos tcard) p lea se a t tach a copy or conf i rm at ion of i ts f i l ing
Please
Sign
Here
Und e r pe na l t i e s o f pe r ju r y , I d ec l a re tha t I have exam ined th i s re tu rn , in c l ud ing a il a ccom pa ny ing fo rm s , sched u les , and a t tachm en ts , an
to
t he^es t p f my know ledge and be l ie f , i t i s t rue , correct , and co mp le te .
D at l
T
Title
Paid
Preparer's
UseOnly
.F>f iepaf^s s ignature
P repa re r ' s nam e
Date
Phone
A d d r e s s
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
3/21
F orm 990
Departmentofthe Treas ury
Internal R e v e n u e S e r v i c e
Return
of Organization Exempt Fro m Incom e Tax
U n d e r
s e c t i o n
501 (c ) , 527 , o r4947(a)(1) of
tfie
I nt e r n a l R e v e n u e
C o d e
(except b lac i t lung
benefit t r us t o r pr iv a t e foundat ion)
The o rgan i za t i on m ay have to useacopy o f th i s r e tu rn to sa t i s fy s ta te repo r t i ng requ i rem en ts .
C M S N o . 1545-0047
2012
O p e n t o Pub l i c
I n s p e c t i o n
A
F o r t h e 2 0 1 2 c a l e n d a r y e a r , o r t a x y e a r b e g i n n i n g JUL 1. 2012 a n d e n d i n g JUN 30, 2013
B C h e c kif
appl i cable ;
1
l A d d r e s s
1
I c h a n g e
1
[Name
1
I c h a n g e
I {Initial
1
Iretum
1 iTernrifn-
1
lated
j
l A m e n d e d
1
1
return
1
l A p p f i c a -
1
Ition
pending
0 Nam e o f o rgan i za t i on
MID
V A L L E Y MENTORS
D E m p l o y e r i d e n t if i c a ti o n n u m b e r
2 0 - 5 5 3 1 2 3 7
B C h e c kif
appl i cable ;
1
l A d d r e s s
1
I c h a n g e
1
[Name
1
I c h a n g e
I {Initial
1
Iretum
1 iTernrifn-
1
lated
j
l A m e n d e d
1
1
return
1
l A p p f i c a -
1
Ition
pending
Doing
Bus iness As
D E m p l o y e r i d e n t if i c a ti o n n u m b e r
2 0 - 5 5 3 1 2 3 7
B C h e c kif
appl i cable ;
1
l A d d r e s s
1
I c h a n g e
1
[Name
1
I c h a n g e
I {Initial
1
Iretum
1 iTernrifn-
1
lated
j
l A m e n d e d
1
1
return
1
l A p p f i c a -
1
Ition
pending
Nu mb er an d stree t (or P.O. box
if
mail is not delivered to street address) Room /suite
3 0 3 0
CENTER S T R E E T
NE
E
T e l e p h o n e n u m b e r
5 0 3 - 4 0 9 - 6 5 3 3
B C h e c kif
appl i cable ;
1
l A d d r e s s
1
I c h a n g e
1
[Name
1
I c h a n g e
I {Initial
1
Iretum
1 iTernrifn-
1
lated
j
l A m e n d e d
1
1
return
1
l A p p f i c a -
1
Ition
pending
Ci ty , town , o r pos t o f f i ce , s ta te , and Z IP cod e
SALEM.OR 9 7 3 0 1
G
G r o s s r e c e i p t s
2 4 3 f 7 4 3 >
B C h e c kif
appl i cable ;
1
l A d d r e s s
1
I c h a n g e
1
[Name
1
I c h a n g e
I {Initial
1
Iretum
1 iTernrifn-
1
lated
j
l A m e n d e d
1
1
return
1
l A p p f i c a -
1
Ition
pending
Ci ty , town , o r pos t o f f i ce , s ta te , and Z IP cod e
SALEM.OR 9 7 3 0 1
H(a)
Is th isag roup re tu rn
for a f f i l ia tes?
L J Y e s L X I N O
H(b)Are all affil iates include d? v e s N o
I f "No , " a t tachal i s t , (see in struc t ions )
H(c) G r o u p e x e m p t i o n n u m b e r
B C h e c kif
appl i cable ;
1
l A d d r e s s
1
I c h a n g e
1
[Name
1
I c h a n g e
I {Initial
1
Iretum
1 iTernrifn-
1
lated
j
l A m e n d e d
1
1
return
1
l A p p f i c a -
1
Ition
pending
F Nam e and ad d ress o f p r i nc i pa l o f f i ce r :SARAH CAVAZOS
SAMEAS CABOVE
H(a)
Is th isag roup re tu rn
for a f f i l ia tes?
L J Y e s L X I N O
H(b)Are all affil iates include d? v e s N o
I f "No , " a t tachal i s t , (see in struc t ions )
H(c) G r o u p e x e m p t i o n n u m b e r
1 T a x - e x e m p t s t a t u s : L X l 501(c)(3) 1 1 501(c) ) -
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
4/21
For m990( 2012) MID VA L LE Y
MENTORS
2 0 - 5 5 3 1 2 3 7 Paae2
P a r t
illIStatement of ProgramS e r v i c e A c c o m p l i s h m e n t s
Che ck if Sche dule 0 conta ins a respo nse to any ques tion in this Part III I I
1 Briefly describe the organization's mission:
TO
P ROVIDE QUA LITYMENTORING FOR A T - R I S K
YOUTH
AND F A M I L I E S THAT
O F F E R S NEW
P E R S P E C T I V E S
ON L I F AND LEADS TO BRIG HTER FUTURES.
2
Did the organ izatio n unde rtake any signifi cant prog ram services during the year whic h were not listed on
th e
prior Form 990 or 990-E2?
CZjYes
C x ] N O
If Yes, describ e these new services on Schedule 0 .
3
Did the organization cease conductin g, or make significant changes In how It cond ucts , any program services? [ZHves IXINo
If Yes, describ e these changes on Schedule O.
4 Describe the organization's program service accompl ishmen ts for each of its three largest program sen/Ices, as measured by expenses.
Sect ion
501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and
revenue, if any, for each program service reported.
4a ( C o d 6 :
)
( E x p e n s e s
7 0 , 6 3 6 .
i nc ludi ng grants o f
)
( R e v e n u e
1 9 , 9 8 4 .
)
THE J U V E N I L E ENRICHMENT
THROUGHMENTORING (JEM)PROGRAM PROV IDES
EVIDENCE-BASED
VOLUNTEER-DRIVEN
MENTORING
FOR
A T - R I S K YOUTH
I N
S A L E M - K E I Z E R
OREGON
WHO
HAVE
A
PARENT
I N PRISON, ARE
UNDER S U P E R V I S I O N
OF THE
J U V E N I L E
DEPARTMENT OR WHO HAVEMUL TIP LE FACTORS ASSOCIA TED
WITH
R I S K
FOR
SCHOOL
F A I L U R E .
DURING
THE
2 0 1 2 - 1 3
F I S C A L
YEAR THE
PROGRAM
PROVIDING
ONE-TO-ONE
MENTORING RELA TIONSH IP S FOR THIRTY-FOUR YOUTH.
4 b ( C o d e :
)
( E x p e n s e s
1 9 3 , 0 9 9 .
i n c l u d i n g g r a n t s o f 8 , 0 0 0 . ) ( R e v e n u e
1 7 0 , 2 0 3 .
)
THE
REENTRY SOLUTIONPROGRAM ( RSP ) PROVIDE PRE- AND POST- REL EASE
T R A N S I T I O N
AND SUPPORT
S E R V I C E S
FOR INCARC ERATED PARENTS
R E L E A S I N G
TO
MARION
COUNTY.
DURING
THE
2 0 1 2 - 1 3 F I S C A L
YEAR THE
PROGRAM
CONDUCTED
F O R T Y - S I X
C L I E N T
ASSESSMENTS. PROVIDED 64
C L I E N T S WITH
PREAND/OR POST
R E L E A S E
MENTORING
AND
F A C I L I T A T E D
F IFTY- TWO TRA NSITI ON
EDUCATION/SUPPORT
GROUPS.
4c
( c o d e :
)
( E x p e n s e s
$ including grants of $ )
( R e v e n u e
$
4d Other pro gra m servic es (Describe in Sche dule O.)
( E x p a n s e s
$
i n c l u d i n a
grants of $ )
( R e v e n u e
$
4e
T o t a l
program
s e r v i c ee xp e n s e s
2 6 3 , 7 3 5 .
Form99 (2012
232002
12-10-12
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
5/21
Part IV
C h e c k l i s t
o f Re q u i re d
S c h e d u l e s
Y e s No
1
I s the o rg an iza t io n de sc r ib e d in sec t io n 501(c ) (3) o r 4947(a ) (1 ) (o t her t han a p r i va te f o und a t io n )?
If Yes, complete Schedule A
1
X
2
I s t he o rgan iza t io n requ i red t o co m p le te Schedule B, Schedule of Contributors
2
X
3
D id t he o rgan iza t io n engag e in d i rec t o r ind i rec t po l it i ca l cam pa ign ac t i v i t i es o n b eha l f o f o r in o ppo s i t i o n t o cand ida tes f o r
pub l i c o f f i ce? If Y es, compiete Schedule C, Part
1
3
X
4 S e c t i o n
5 0 1 ( c X 3 ) o r g a n i z a t i o n s .D id t he o rgan iza t io n engag e in l o b b y ing ac t i v i t i es , o r have a sec t io n 5 01 (h ) e lec t io n i n e f f ec t
dur ing t he t ax year?
If Yes, complete Schedule C, Part li
4
X
5 I s t he o rgan iza t io n a sec t io n 501 (c)(4),5 0 1(c)(5),o r 501 (c )(6 ) o rgan iza t io n t ha t rece ives m emb ersh ip due s , assessm ents , o r
s i m il a r a m o u n t s a s d e f i n e d i n R e v e n u e P r o c e d u r e 9 8 - 1 9 ? T e s , " c o m p / e fe S c h e d u / e C , P a r t / / /
5
X
6
D id t he o rgan iza t io n ma in ta in any do no r adv i sed f unds o r any s im i l a r f und s o r acc o un t s f o r wh ic h do no rs have t he r i gh t t o
p ro v ide adv ice o n t he d i s t r i b u t io n o r i nves tment o f amo unt s i n such f unds o r acco un t s?
If Yes, compiete Schedule D, Part1
7
D id t he o rgan iza t io n rece ive o r ho ld a co nsen /a t i o n easem ent , i nc lud ing easeme nts t o p reserve o pen space ,
t he env i ro nme nt , h i s t o r ic l and a reas , o r h i s t o r i c s t n j c t u res ? If Yes, compie te Schedu le D, Part II . .
6
X
6
D id t he o rgan iza t io n ma in ta in any do no r adv i sed f unds o r any s im i l a r f und s o r acc o un t s f o r wh ic h do no rs have t he r i gh t t o
p ro v ide adv ice o n t he d i s t r i b u t io n o r i nves tment o f amo unt s i n such f unds o r acco un t s?
If Yes, compiete Schedule D, Part1
7
D id t he o rgan iza t io n rece ive o r ho ld a co nsen /a t i o n easem ent , i nc lud ing easeme nts t o p reserve o pen space ,
t he env i ro nme nt , h i s t o r ic l and a reas , o r h i s t o r i c s t n j c t u res ? If Yes, compie te Schedu le D, Part II . .
7
X
8
D id t he o rgan iza t io n ma in ta in co l l ec t i o ns o f wo rks o f a r t , h i s t o r i ca l t reasures , o r o t her s im i l a r asse t s?
If Yes, compiete
Scheduie D, Part iii
8
X
9
D id the orga niza t ion rep ort an am oun t in Part X, l ine 2 1 , f o r esc ro w o r cus to d ia l acco u n t l i ab i l it y ; se rve as a cus to d ia n f o r
am o un t s no t l i s t ed i n Par t X ; o r p ro v ide c red i t co unse l i ng , deb t man age men t , c red i t repa i r , o r deb t neg o t ia t i o n se rv i ces?
If
Yes, compiete Schedule D, Part IV
9
X
10
D id t he o rgan iza t io n , d i rec t l y or t h ro u gh a re la t ed o rgan iza t io n , ho ld asse t s i n t empo rar i l y res t r i c t ed en do w me nts , pe rman ent
e n d o w m e n t s , o r q u a s i - e n d o w m e n t s ?
If Yes,' complete Schedule D, Part V
10
X
11 I f t he o rgan iza t io n ' s answer t o any o f t he f o ll o w ing ques t io ns i s "Yes , " t hen co m p le te Sch edu le D, Par t s VI ,V I I ,
V l l l ,
IX, or X
as app l i cab le .
a
D id t he o rgan iza t io n repo r t an amo u nt f o r
l and ,
b u i l d ings , and equ ipm ent i n Par t X , l i ne 10? If
Yes,
compiete Scheduie D,
Part
VI
11a
X
b
D id the organ izat ion re port an amo un t fo r investm en ts o ther sec ur i t ies in Part X, l ine 12 that is 5% or more o f it s to ta l
assets reported in Part X, l ine 16? If
Yes,
complete Schedule D, Part Vll
l ib
X
c D id the organiza t ion repor t an am oun t fo r invest me nts - pro gra m related in Part X, l ine 13 that is 5% or more o f i t s to ta l
asse t s rep o r t ed i n Par t X , l ine 16?
If Yes, compiete Schedule D, Part Vlii
11c
X
d
D id the organ izat ion rep ort an amo unt fo r o the r ass ets In Part X, l ine 15 tha t is 5% or more o f Its to ta l asse ts reporte d in
Part X, l ine 16? if Yes, compiete Schedule D, Part IX
l id
X
e
D id the orga niza t ion repor t an amo un t fo r o the r l iab i l i ties in Part X, l ine 25 ?
If Yes, complete Scheduie D, Part X
l i e
X
f
D id t he o rgan iza t io n ' s separa te o r co nso l i da ted f i nanc ia l s t a t em ent s f o r t he t ax year inc lude a f o o tno te t ha t add resses
the o rga n iza t io n ' s l i ab il i ty f o r uncer t a in t ax po s i t i o ns und er F IN 48 (ASC 740)? If Yes, complete Scheduie D, Part X
l i t
X
1 2a D id t he o rgan iza t io n o b ta in separa te , i nde pen den t aud i t ed fi nanc ia l s t a t em ent s f o r t he t ax year? if Yes, complete
Schedule
D, Parts Xi and XII
12a
X
b
Was t he o rgan iza t io n i nc luded in co nso l i d a ted , i ndep ende n t aud i t ed fi nanciad s t a t em ent s f o r t he t ax year?
If
"Ves, "and if the organization answered No to line 12a, then completing Schedule D, Parts Xi and Xii is optional 12b
X
13
I s the orga niza t ion a sch oo l des cr ib ed in sec t ion 170(b)(1)(A)( ii )? If Yes, com plete Schedule E
13
X
1 4a
D id t he o rgan iza t io n ma in ta in an o f f ice , emp lo yees , o r agen t s o u t s ide o f t he Un i t ed S ta tes?
14a
X
b
D id t he o rgan iza t io n have aggrega te revenues o r expen ses o f mo re t han $10 ,00 0 f ro m gran tmak ing , f und ra i s ing , b us ine ss ,
i nves tment , and p ro gram serv i ce ac t i v i t i es o u t s ide t he Un i t ed S ta tes , o r aggrega te f o re ign i nves tment s va lued a t $100 ,000
o r mo re?
If Yes, complete Scheduie F, Parts
1
and IV
14b
X
15 D id t he o rgan iza t io n repo r t o n Par t IX , co lum n (A), l i ne 3 , mo re t han $5 ,000 o f g ran t s o r ass i s t anc e t o any o rgan iza t io n
or
en t i t y l o ca ted o u t s ide t he Un i t ed S ta tes?
If Yes,' complete Schedule F, Parts II and IV 15
X
16
D id t he o rgan iza t io n repo r t o n Par t IX , co lum n (A), l i ne 3 , mo re t han $5 ,000 o f aggrega te g ran t s o r ass i s t an ce t o i nd i v idua l s
lo ca ted o u t s ide t he Un i t ed S ta tes? if
Yes,
complete Schedule F, Parts
iii
and IV
16
X
17
D id t he o rgan iza t io n repo r t a t o t a l of mo re t han $15 ,000 o f expe nses f o r p ro fess io na l f und ra i s ing se rv i ces o n Par t IX ,
c o l u m n
(A) , l ines 6 and
l i e ? / r ' / e s , c o m p / e f e S c h e c f u t e
G , P a r t /
17
X
18
D id t he o rgan iza t io n repo r t mo re t han $15 ,000 t o t a l o f f und ra i s in g even t g ro ss i nco me and co n t r i b u t io ns o n Par t
V l l l ,
l ines
1 c and 8a? If 'Yes, comple te Schedu le G, Part li
18
X
19
D id t he o rgan iza t io n repo r t mo re t han $15 ,0 00 o f g ro ss i nco me f ro m gam ing ac t iv i t i es o n Par t
V l l l ,
l ine 9a?
If Yes,
complete
Schedu le G, Part III
19
X
2 0 a
D id t he o rgan iza t io n o pera te o ne o r mo re ho sp i t a l f ac i l i ti es?
If Yes, complete Schedule hi
2 0 a
X
b
If "Yes " t o li ne 20a , d id t he o rqan iza t io n a t t ach a co py o f it s aud i t e d fi nanc ia l s t a t em ent s t o t h i s re t u rn?
20b
Fo rm
99
(2012
232003
12-10-12
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
6/21
Part IV
C h e c k l i s t
o f R e q u i r e d
S c h e d u l e s
(continued)
Y e s
No
21
D id the o rgan i za t i on repo r t m ore than $5 ,000 o f g ran ts and o the r ass i s tance to any gove rnm en t o r o rgan i za t i on i n the
United S ta tes on Par t IX , co lumn (A) , l ine 1 ?
If Yes, complete Sctiedule
1,
Parts
1
and II
21
X
22
D id the o rgan i za t i on repo r t m ore than $5 ,000 o f g ran ts and o the r ass i s tanc e to ind i v i d ua l s In the Un i ted S ta tes on P a r t IX ,
column (A), l ine 2? If Yes, complete Scheduie 1, Parts 1and Ili
22
X
23 D id the o rgan i za t i on answ e r "Yes" to P a r t V l l , Sec t i on A , line 3 ,4 , o r 5 abou t com pensa t i on o f the o rgan i za t i on ' s cu r ren t
an d fo rm e r o f f i ce rs , d i r ec to rs , t r us tees , key em p loyees , and h i ghes t com pensa ted em p loyees?
If Yes, complete
Scheduie J
23 X
2 4 a D id the o rgan i za t i on have a tax -exem p t b ond i ssue w i th an ou ts tand ing p r i nc i pa l am o un t o f m ore than $100,000 as of the
last d ay o f the yea r , tha t was i ssued a f te r Decem ber 3 1 , 2 0 0 2 ? If Yes, answer lines 24b through 24 d and complete
Scheduie K. If No , go to line 25
2 4 a
X
b D id the o rgan i za t i on i nves t any p roce ed s o f tax -exem p t bond s bey ond a tem p ora ry pe r i od ex cep t i on ?
24b
c
D id the o rgan i za t i on m a in ta i n an esc row acc oun t o the r than a re fund ing esc row a t any t im e d u r i ng the yea r to d e fease
any
t a x -e x e m p t b o n d s ?
2 4 c
d
D id the o rgan i za t i on ac t as an "on beha l f o f " i ssue r fo r bond s ou ts tan d ing a t any t im e d u r i ng the yea r?
24d
2 5 a S e c t i o n501(c)(3) a n d501(c)(4) o r g a n i z a t i o n s . D id the o rgan i za t i on engage i n an excess bene f i t t r ansac t i on w i th a
disqualified pe rson d u r i ng the yea r? If Yes, complete Scheduie L, Part1
2 5 a
X
b I s the o rgan i za t i on aw a re tha t i t engag ed i n an excess b ene f i t t r ansac t i on w i th a d i squa l i f i ed pe rson i n a p r i o r yea r , and
that
t he t r ansac t i on has no t been repo r ted on any o f the o rgan i za t i on ' s p r i o r F o rm s 990 o r 990 -EZ?
If Yes, complete
Schedule L, Part 1
25b
X
26
Wa s a l oan to o r by a cu r ren t o r fonne r o f f i ce r , d i r ec to r , tm s tee , key em p loyee , h i ghes t com p ens a ted em p loyee , o r d i squa l i f i ed
person ou ts tand ing as o f the end o f the o rgan i za t i on ' s tax yea r?
If Ye s, complete Schedule L, Part II
26
X
27 D id the o rgan i za t i on p rov i d e a g ran t o r o the r ass i s tance to an o f f i ce r , d i r ec to r , tm s tee , key em p loy ee , sub s tan t i a l
con t r i bu to r o r em p loyee the reo f , a g ran t se l ec t i on com m i t tee m em ber , o r to a 35% con t ro l l ed en t i t y o r fam i l y m em ber
o f any o f these pe rsons? If Y es, complete Scheduie L, Part III
27 X
28
Was the o rgan i za t i on a pa r ty to a bus iness t r ansac t i on w i th one o f the fo l l ow ing pa r t i e s ( see Sche d u le L , P a r t IV
i ns tm c t i ons fo r app l i cab le f i l i ng th resho ld s , cond i t i ons , and excep t i ons ) :
a A cu r ren t o r fonne r o f f ice r , d i rec to r , tm s te e , o r key em p loyee? if Yes, compiete Scheduie L, Part IV
2 8 a
X
b A fam i l y m em ber o f a cu r ren t o r fo rm e r o f f i ce r , d i r ec to r , tm s tee , o r key em p loyee ? if Yes, compiete Schedule L, Part IV
28b
X
c An en t i t y o f wh i ch a cun -ent o r fo rm e r o f f i ce r , d i r ec to r , tm s te e , o r key em p loye e (o r a fam i l y m em ber the reo f ) was an o f f i ce r ,
director, tm s tee , o r d i r ec t o r i nd i rec t owne r?
If Yes, compiete Schedule L, Part IV
2 8 c
X
29 D id the o rgan i za t i on rece i ve m ore than $25 ,000 in non -cash con t r i bu t i on s? if Yes, complete Schedule M 29
X
30 Did t he o rgan i za t i on rece i ve con t r i bu t i ons o f a r t , h i s to r i ca l t r easu res , o r o the r s im i l a r asse ts , o r qua l if i ed conse rva t i on
contributions? If Yes, compiete Scheduie M
30
X
31 D id the o rgan i za t i on l i qu i d a te , te rm ina te , o r d i sso l ve and cease ope ra t i ons?
if Yes,' complete Schedule N, Part1
31
X
32 D id the o rgan i za t i on se l l , e xchange , d i spose o f , o r t r ans fe r m ore than 25% o f i t s ne t asse ts? / f Yes, compiete
Scheduie N, Part II
32 X
33 D id the o rgan i za t i on ow n
1 0 0 %
o f an en t i t y d i s rega rd ed as sepa ra te f r om the o rgan i za t i on und e r Regu la t i ons
s e c t i o n s301.7701-2 an d 301.77 01 -3?
If Yes, compiete Schedule
R,
Part
1
33
X
34 Was the o rgan i za t i on re l a ted to any tax -exem p t o r taxab le en t i t y? If 'Yes, compiete Schedule R, Part II, ill, or IV, and
PartV, iine 1
34 X
3 5 a D id the o rgan i za t i on have a con t ro l l ed en t i t y w i th i n the m ean ing o f sec t i on 512(b)(13)? 3 5 a
X
b
I f "Yes" to l ine 35a , d i d the o rgan i za t i on rece i ve any paym en t f r om o r engag e i n any t r ansac t i on
with
a con t ro l l ed en t i t y
within
t he m ean ing o f sec t i on
512(b)(13)?
If 'Yes, complete Schedule R, Part V, line 2
35b
36
S e c t i o n
501(c)(3)
o r g a n i z a t i o n s .Did t he o rgan i za t i on m a ke any t r ans fe rs to an exem p t non -cha r i tab l e re l a ted o rgan i za t i on?
If
Yes, compiete Schedule R, Part V, line 2
36
X
37 D id the o rgan i za t i on con d u c t m ore than 5% o f it s ac t i v i t i e s th rou gh an en t i t y tha t is no t a re l a ted o rgan i za t i on
and t ha t i s t r ea ted as a pa r tne rsh ip fo r fed e ra l i n com e tax pu rpose s? If Yes, compiete Schedule R, Part VI
37 X
38
Did t he o rgan i za t i on com p le te Sched u le 0 a nd p rov i d e exp lan a t i ons i n Sche d u le 0 fo r P a r t V I , l i nes l i b a n d 19?
Note.
A l l F o rm 990 f i l e rs a re requ i red to com p le te Sc hed u le 0
38
X
F o r m
99 0
(2012
232004
12-10-12
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
7/21
F orm
990 (2012)
MID
V A L L E Y MENTORS 2 0 - 5 5 3 1 2 3 7
PaaeS
P a r t V
S t a t e m e n t s R e g a r d i n g O t h e r I R S
F i l ings
a n d T a x C o m p l i a n c e
Check i f Sche d u le O con ta i ns a respons e to any ques t i on i n th i s P a r t V
Y e s No
l a En te r the num b e r repo r ted i n Box 3 o f F o rm 1096 . En te r
-0-
i f not app l icable
l a 0
I c
b
En te r the num be r o f F o rm s W-2G i nc l ud ed i n l ine
l a .
En te r -O- I f not app l icable
l b 0
I c
0 D id the o rgan i za t i on com p l y w i th bac kup w i thho ld i ng ru les fo r r epo r tab l e paym en ts to vend o rs and repo r tab l e gam ing
(gam b l i ng ) w inn ings to p r i ze w inne rs?
I c
2 a
En te r the num b e r o f em p loyee s repo r ted on F o rm W-3 , T ransm i t ta l o f Wa ge and Tax S ta tem e n ts ,
filed
fo r the ca l end a r yea r end ing w i th o r w i th i n the yea r cove red by th i s re tu rn 2 a
1 3
2b
X
I f a t least one is repor ted on l ine 2a, d id the organ iza t ion f i le a l l requ i red federa l employment tax re tur
Note. I f the sum of l ines 1 a and 2a Is g rea te r than 250 , you m ay be requ i red to e-file ( see i ns tm c t i ons
3 a D id the o rgan i za t i on have un re l a ted bus iness g ross i ncom e o f $1,000 o r m ore d u r i ng the yea r?
ns?
2b
X
I f a t least one is repor ted on l ine 2a, d id the organ iza t ion f i le a l l requ i red federa l employment tax re tur
Note. I f the sum of l ines 1 a and 2a Is g rea te r than 250 , you m ay be requ i red to e-file ( see i ns tm c t i ons
3 a D id the o rgan i za t i on have un re l a ted bus iness g ross i ncom e o f $1,000 o r m ore d u r i ng the yea r?
)
3 a
X
b I f "Ye s," has i t f i led a Form 990-T for th is year? If No, provide an expianation in Scheduie 0
3b
4 a
A t any t im e d u r i ng the ca l end a r yea r , d i d the o rgan i za t i on have an i n te res t i n , o r a s i gna tu re o r o the r au tho r
financial a cco un t i n a fo re i gn coun t r y ( such as a bank acc oun t , secu r i t i e s acc oun t , o r o the r f i nanc ia l acco u
b
I f "Yes , " en te r the nam e o f the fo re i gn cou n t r y :
ty over , a
nt)?
4 a X
4 a
A t any t im e d u r i ng the ca l end a r yea r , d i d the o rgan i za t i on have an i n te res t i n , o r a s i gna tu re o r o the r au tho r
financial a cco un t i n a fo re i gn coun t r y ( such as a bank acc oun t , secu r i t i e s acc oun t , o r o the r f i nanc ia l acco u
b
I f "Yes , " en te r the nam e o f the fo re i gn cou n t r y :
5 a
X
See
i n s tm c t i ons fo r f i l i ng requ i rem en ts fo r F o rm TD F 9 0 - 2 2 . 1 , Repo r t o f F o re ign Bank and F inanc ia l /
5 a Wa s the o rgan i za t i on a pa r ty to a p roh ib i ted tax she l te r t r ansac t i on a t any t im e d u r i ng the tax yea r?
b D id any taxab le pa r ty no t i f y the o rgan i za t i on tha t i t was o r I s a pa r ty to a p roh ib i ted ta x she l te r t r ansa
Accoun ts .
5 a
X
See
i n s tm c t i ons fo r f i l i ng requ i rem en ts fo r F o rm TD F 9 0 - 2 2 . 1 , Repo r t o f F o re ign Bank and F inanc ia l /
5 a Wa s the o rgan i za t i on a pa r ty to a p roh ib i ted tax she l te r t r ansac t i on a t any t im e d u r i ng the tax yea r?
b D id any taxab le pa r ty no t i f y the o rgan i za t i on tha t i t was o r I s a pa r ty to a p roh ib i ted ta x she l te r t r ansa
ction?
5b
X
c I f "Yes ," to l ine 5a or 5b , d id the organ iz a t ion f i le Form 888 6-T?
5 c
6 a Does the o rgan i za t i on have annua l g ross rece ip ts tha t a re no rm a l ly g rea te r than $10 0 ,00 0 , and d i d the o rgan i za t i on so l i c i t
any
con t r i bu t i ons tha t we re no t tax d ed uc t i b l e as cha r i tab l e con t r i bu t i ons?
6 a
X
b
I f "Yes , " d i d the o rgan i za t i on i nc l ud e w i th eve ry so l i c ita t i on an exp ress s ta te m en t tha t such con t r i bu t i ons o r g i f t s
were no t tax d ed uc t i b l e?
6b
7 O r g a n i z a t i o n sthat m a y r e c e i v e d e d u c t i b l e c o n t r ib u t i o n s u n d e r s e c t i o n 170(c) .
a Did the organization receive a paymen t in excess of $75 made partly as a contr ibution and partly for good s and sen/Ices provided to the payor?
b
I f "Yes , " d i d the o rgan i za t i on no t i f y the d ono r o f the va l ue o f the good s o r sen / i ces p rov i d ed ?
7 a
X
7 O r g a n i z a t i o n sthat m a y r e c e i v e d e d u c t i b l e c o n t r ib u t i o n s u n d e r s e c t i o n 170(c) .
a Did the organization receive a paymen t in excess of $75 made partly as a contr ibution and partly for good s and sen/Ices provided to the payor?
b
I f "Yes , " d i d the o rgan i za t i on no t i f y the d ono r o f the va l ue o f the good s o r sen / i ces p rov i d ed ?
7b
c
D id the o rgan i za t i on se l l , e xchange , o r o the rw i se d i spose o f tang ib l e pe rsona l p rope r ty fo r wh i ch i t was requ i red
to
f i l e F o rm 8282?
7 c
X
d
I f "Yes , " i nd i ca te the num be r o f
Fomns
8282 f i led dur ing the year 7 d
7e
X
Did the o rgan i za t i on rece i ve any fu nd s , d i r ec t l y o r Ind i rec tl y , to pay p rem ium s o n a pe rsona l bene f i t con t rac
f Did t he o rgan i za t i on , d u r i ng the yea r , pay p rem ium s, d i r ec t l y o r i nd i rec t l y , on a pe rsona l bene f i t con t rac t?
g I f t he o rgan i za t i on rece i ved a con t r i bu t i on o f qua l i f i ed i n te l le c tua l p rope r ty , d i d the o rgan i za t i on f il e F o rm88
;t?
7e
X
Did the o rgan i za t i on rece i ve any fu nd s , d i r ec t l y o r Ind i rec tl y , to pay p rem ium s o n a pe rsona l bene f i t con t rac
f Did t he o rgan i za t i on , d u r i ng the yea r , pay p rem ium s, d i r ec t l y o r i nd i rec t l y , on a pe rsona l bene f i t con t rac t?
g I f t he o rgan i za t i on rece i ved a con t r i bu t i on o f qua l i f i ed i n te l le c tua l p rope r ty , d i d the o rgan i za t i on f il e F o rm88
7f
X
e D id the o rgan i za t i on rece i ve any fund s , d i r ec t l y o r Ind i rec t ly , to pay p rem ium s o n a pe rson a l bene f i t con t rac
f Did t he o rgan i za t i on , d u r i ng the yea r , pay p rem ium s, d i r ec t l y o r i nd i rec t l y , on a pe rsona l bene f i t con t rac t?
g I f t he o rgan i za t i on rece i ved a con t r i bu t i on o f qua l i f i ed i n te l le c tua l p rope r ty , d i d the o rgan i za t i on f il e F o rm88
99 a s requ i red ?
79
X
h
I f t he o rgan i za t i on rece i ved a con t r i bu t i on o f ca rs , boa t s , a i r p lanes , o r o the r veh i c l es , d i d the o rgan i za t i on f il e a F o rm
1098-C?
8 Sponsoring
organizations maintaining donor
advised
funds and
section
509(a)(3) supporting organizations.
Did the supporting
organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any
time
during the year?
9 S p o n s o r i n g o r g a n i z a t i o n s m a i n t a i n i n g d o n o r a d v i s e df u n d s .
a
D id the o rgan i za t i on m ake any taxab le d i s t r i bu t i ons und e r sec t i on 49 66?
7h
X
I f t he o rgan i za t i on rece i ved a con t r i bu t i on o f ca rs , boa ts , a i r p lanes , o r o the r veh i c l es , d i d the o rgan i za t i on f i le a F o rm
1098-C?
8 Sponsoring
organizations maintaining donor
advised
funds and
section
509(a)(3) supporting organizations.
Did the supporting
organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any
time
during the year?
9 S p o n s o r i n g o r g a n i z a t i o n s m a i n t a i n i n g d o n o r a d v i s e df u n d s .
a
D id the o rgan i za t i on m ake any taxab le d i s t r i bu t i ons und e r sec t i on 49 66?
8
X
h
I f t he o rgan i za t i on rece i ved a con t r i bu t i on o f ca rs , boa t s , a i r p lanes , o r o the r veh i c l es , d i d the o rgan i za t i on f il e a F o rm
1098-C?
8 Sponsoring
organizations maintaining donor
advised
funds and
section
509(a)(3) supporting organizations.
Did the supporting
organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any
time
during the year?
9 S p o n s o r i n g o r g a n i z a t i o n s m a i n t a i n i n g d o n o r a d v i s e df u n d s .
a
D id the o rgan i za t i on m ake any taxab le d i s t r i bu t i ons und e r sec t i on 49 66?
9 a X
b D id the o rgan i za t i on m ake a d i s t r i bu t i on to a d ono r , d on o r ad v i so r , o r r e l a ted pe rs on?
9b
X
10 S e c t i o n 5 0 1 ( c K 7 ) o r g a n i z a t i o n s . Enter :
a I n i t i a ti on fees and cap r ta l con t r i b u t i ons i nc l ud ed on P a rt V l l l , l ine 12
10a
12a
b G ross rece ip ts , i n c l ud e d on F o rm 990 , P a rt V l l l , l ine 1 2 , for publ ic use of c lub fac i l i t ies
10b
12a
11 S e c t i o n
501(c)(12)o r g a n i z a t i o n s .
Enter :
a
G ross i ncom e f rom m em bers o r sha reho ld e rs
11a
12a
b G ross i ncom e f rom o the r sou rces (Do no t ne t am o un ts d ue o r pa id to o the r sou rc es aga ins t
am oun ts d ue o r r ece i ved f rom them . )
l ib
12a
2a S e c t i o n 4947(a)(1)n o n - e x e m p t c h a r i t a b l e t r u s t s . Is the organ iza t ion f il ing Fo rm 990 in
lieu
of Fomn
1041?
b I f "Yes ,"enter the am oun t o f tax -exem p t i n te res t r ece i ved o r accm ed d u r i ng the yea r 12b |
12a
2a S e c t i o n 4947(a)(1)n o n - e x e m p t c h a r i t a b l e t r u s t s . Is the organ iza t ion f il ing Fo rm 990 in
lieu
of Fomn
1041?
b I f "Yes ,"enter the am oun t o f tax -exem p t i n te res t r ece i ved o r accm ed d u r i ng the yea r 12b |
13 S e c t i o n
501(c)(29)
qua l i f i ed nonpr o f i t h ea l t h i n s u r a n c e i s s u e r s .
a
I s the o rgan i za t i on l i censed to I ssue qua l i f i ed hea l th p l ans in m ore than one s ta te?
13 S e c t i o n
501(c)(29)
qua l i f i ed nonpr o f i t h ea l t h i n s u r a n c e i s s u e r s .
a
I s the o rgan i za t i on l i censed to I ssue qua l i f i ed hea l th p l ans in m ore than one s ta te?
13a
Note. See the i ns tm c t i ons fo r ad d i t i ona l i n fo rm a t i on the o rgan i za t i on m us t r epo r t on Sched u le 0 .
b En te r the am o un t o f r ese rves the o rgan i za t i on I s requ i red to m a in ta i n by the s ta tes i n wh i ch th e
organization Is l i censed to issue qua l i f ied hea l th p lans
13b
c
En te r the am oun t o f r ese rves on hand
13c
14a D id the o rgan i za t i on rece i ve any paym en ts fo r ind oo r tann ing se rv i ces d u r i ng the tcix yea r?
14a
X
b I f "Yes ," has it f iled a Form 720 to repo r t the se oavments? If No, provide an explanation in Scheduie O
14b
Form
9 90
(2012
232005
12-10-12
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
8/21
F o r m99 0 (2012)
MID
V A L L E Y MENTORS
2 0 - 5 5 3 1 2 3 7 PaoeS
Part V I
I G o v e r n a n c e ,
M a n a g e m e n t , a n d
D is c l o s ur e Foreach T e s " response to lines 2 through 7b beiow, and for a No response
to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check i f Sched u le O con ta i ns a response to any ques t i on i n th i s P a r t V I LXj
S e c t i o n A . G o v e m i n g B o d y a n d M a n a g e m e n t
Y e s No
l a En te r the num b e r o f vo t i ng m em bers o f the gove rn ing bod y a t the end o f the tax yea r l a
7
2
X
If there are material differences in voting rights among members of the governing body, or if the governing
bodydelegated broad authority to an executive committee or similar committee, explain in Schedule 0.
b
En te r the num be r o f vo t i ng m em bers i nc l ud ed i n l ine 1 a , above , wh o a re i nd epe nd en t
lb
7
2
X
2 D id any o f f i ce r , d i r ec to r , tm s tee , or key em p loyee have a fam i l y r e l a t i onsh ip o r a bus iness re l a t i onsh ip w i th any o the r
officer, d i r ec to r , tm s tee , o r key em p loyee? 2
X
3 D id the o rgan i za t i on d e l ega te con t ro l ove r m ana gem e n t d u t i es cus tom ar i l y pe r fo rm ed by o r und e r the d i r ec t supe rv i s i on
o f
o f f i ce rs , d i r ec to rs , o r tm s tees , o r key em p loyees to a m anagem en t com pany o r o the r pe rson?
3
X
4 D id the o rgan i za t i on m ake any s i gn i f i can t chan ges to i t s gove rn ing d ocu m en ts s i nce the p r i or F o rm 990 wa
5 D id the o rgan i za t i on beco m e awa re d u r i ng the yea r o f a s i gn i f i can t d i ve rs i on o f the o rgan i za t i on ' s asse ts ?
6 D id the o rqan i za t i on have m em b ers o r s tock ho ld e rs ?
s f i led?
4 XDid the o rgan i za t i on m ake any s i gn i f i can t changes to i t s gove rn ing d ocum en ts s i nce the p r i o r F o rm 990 wa
5 D id the o rgan i za t i on beco m e awa re d u r i ng the yea r o f a s i gn i f i can t d i ve rs i on o f the o rgan i za t i on ' s asse ts ?
6 D id the o rqan i za t i on have m em b ers o r s tock ho ld e rs ?
5 X
4 D id the o rgan i za t i on m ake any s i gn i f i can t chan ges to i t s gove rn ing d ocu m en ts s i nce the p r i or F o rm 990 wa
5 D id the o rgan i za t i on beco m e awa re d u r i ng the yea r o f a s i gn i f i can t d i ve rs i on o f the o rgan i za t i on ' s asse ts ?
6 D id the o rqan i za t i on have m em b ers o r s tock ho ld e rs ? 6 X
7 a
D id the o rgan i za t i on have m em bers , s tockho ld e rs , o r o the r pe rsons wh o had the pow e r to e l ec t o r appo in t one o r
more m em bers o f the gove rn ing bod y?
7 a X
b
A re any gove rnanc e d ec i s i ons o f the o rgan i za t i on rese rved to ( or sub jec t to app rova l by ) m em ber s , s tockho ld e rs , o r
p e r s o n s o t h e r t h a n t h e g o v e m i n g b o d y ? 7b
X
8
Did the organization contemp oraneous ly docum ent the meetings held or written actions undertaken during the year by the follow ing:
a T h e g o v e m i n g b o d y ?
8 a X
b
Each com m i t tee w i th au tho r i t y to ac t on beha l f o f the govem in g b od y?
8b
X
9 I s the re any o f f ice r , d i r ec to r , tm s tee , o r key em p loyee l i s ted in P a r t V l l , Sec t i on A , wh o canno t be reached a t the
o raan i za t i on ' s m a i l i nq ad d ress? If 'Yes, provide the names and addresses in Schedule 0
9 X
S e c t i o n
B .
P o l i c i es (This Section
S
requests information about policies not required by the intemal Revenue Code.)
Y e s No
1 0a
D id the o rgan i za t i on have l oca l chap te rs , b ranc hes , o r a ff i l ia tes?
10a
X
b
I f "Yes , " d i d the o rgan i za t i on have wr i t ten po li c i es and p roced u re s gove rn ing the ac t i v i t i e s o f suc h chap te rs , a f f il i a tes ,
and b ranches to ensu re the i r ope ra t i ons a re cons i s ten t w i th the o rgan i za t i on ' s exem p t pu rposes? 10b
1
l a H as the o rgan i za t i on p rov i d ed a com p le te co py o f th i s F o rm 990 to a l l m em bers o f i t s gove rn ing bod y be fo re fi l ing the fo rm ?
b
Desc r i be i n Sch ed u le 0 the p roces s , if any , used by the o rgan i za t i on to rev i ew th i s F o rm 990 .
1 2 a D id the o rqan i za t i on have a wr i t ten con f l i c t o f i n te res t po l i cy? If No, go to line 13
11a
X
l a H as the o rgan i za t i on p rov i d ed a com p le te co py o f th i s F o rm 990 to a l l m em bers o f i t s gove rn ing bod y be fo re fi l ing the fo rm ?
b
Desc r i be i n Sch ed u le 0 the p roces s , if any , used by the o rgan i za t i on to rev i ew th i s F o rm 990 .
1 2 a D id the o rqan i za t i on have a wr i t ten con f l i c t o f i n te res t po l i cy? If No, go to line 13 12a
X
b
Were officers , directors, or trustees, and key employees required to disclose annually interests that could give rise to cor
c D id the o rgan i za t i on regu la r i y and cons i s ten t l y m on i to r and en fo rce com p l i anc e w i th the po l i cy?
If Yes, d
in
Schedule 0 how this was d one
flicts?
12b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to cor
c D id the o rgan i za t i on regu la r i y and cons i s ten t l y m on i to r and en fo rce com p l i anc e w i th the po l i cy?
If Yes, d
in
Schedule 0 how this was d one
escribe
12c
13 D id the o rgan i za t i on have a wr i t ten wh i s t l eb l owe r po l i cy? 13
X
14
Did
t he o rgan i za t i on have a wr i t ten d ocum en t re ten t i on and d es tm c t i on po l i cy? 14 X
15 D id the p roces s fo r d e te rm in ing com pen sa t i on o f the fo l l ow ing pe rsons i nc l ud e a rev i ew and app rova l by i nd epe nd en t
pe rson s , com p a rab i l i t y d a ta , and con tem poran eous su bs tan t i a t i on o f the d e l ibe ra t i on and d ec i s i on?
a Tbe o rgan i za t i on ' s CEO, Execu t i ve D i rec to r , o r top m anagem en t o f f i c i a l 15a
X
b O the r o f f i ce rs o r key em p loyee s o f the o rgan i za t i on
15b
X
I f "Yes" to l i ne 15a o r 15b , d esc r i be the p roces s i n Sche d u le 0 ( see i ns tm c t i o ns ) .
16 a D id the o rgan i za t i on i nves t i n , con t r i bu te asse ts to , o r pa r t i c i pa te i n a j o i n t ven tu re o r s im i l a r a r rangem en t w i th a
taxable
en t i t y d u r i ng the yea r? 16a
X
b
I f "Yes , " d i d the o rgan i za t i on fo l low a wr i t ten po l i cy o r p roced u re requ i r i ng the o rgan i za t i on to eva lua te i ts pa r t i c i pa t i on
in jo i n t ven tu re a r rangem en ts un d e r app l i cab le fed e ra l tax l aw , and take s te ps to sa fegua rd the o rgan i za t i on ' s
exemot
s ta tus w i th respec t to such an-anqements?
16b
S e c t i o n
C .
D is c l o s ur e
17
18
List t he s ta tes w i th w h i ch a co py o f th i s F o rm 990 i s r equ i red to be f i led
O R
Section 6104 r equ i res an o rgan i za t i on to m ake i t s F o rm s 1023 (o r1024 i f app l icab le) , 990, and 990-T (Sect ion 501(c) (3)s on ly) ava i lab le
fo r pub l i c i n spec t i on . Ind i ca te how you m a d e these ava i l ab l e . Che ck a l l t ha t app l y .
I
I Ow n web s i te I
I
Ano th e r ' s webs i te I
X
I Up on reques t I I O the r
(explain in Scheduie O)
Describe
i n Sch ed u le 0 whe the r ( and i f so , how) , the o rgan i za t i on m a d e i t s gove rn ing d ocu m e n ts , con f l i c t o f i n te res t po l i cy , and f i nanc ia l
s ta te m en ts ava i l ab le to the pub l i c d u r i ng the tax yea r .
State t he nam e , phys i ca l ad d ress , and te l ephon e num b e r o f the pe rson w ho poss esse s the books and rec o rd s o f the o rgan i za t i on :
SARAH S P I N K S - 5 0 3 - 5 8 4 - 4 8 6 5
3 0 3 0 CENTER S T R E E T N E . SALEM. O R 9 7 3 0 1
12-10-12
19
20
Form
9 9 0
(201
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
9/21
F o r m9 90 (2012)
MID
V A L L E Y MENTORS
2 0 -5531237 P a g e ?
C o m p e n s a t i o n of
O f f i c e r s ,
D i r e c t o r s ,
T r u s t e e s ,
K e y
E m p l o y e e s ,
H i g h es t C o m p e n s a t e d
E m p l o y e e s ,
a n d In d e p e n d en t C o n t r a c t o r s
Check i f Sch ed u le 0 con ta i ns a response to any que s t i on i n th i s P a r t V l l
S e c t i o n
A .
O f f i c e r s ,
D i r e c t o r s .T r u s t e e s , K e y E m p l o y e e s , a n d H i g h e s t C o m p e n s a t e d E m p l o y e e s
l a Complete this table for all person s required to be listed. Report compe nsation for the calendar year ending with or within the organization's tax year.
L i s t a ll o f the o rgan i za t i on ' s
c u r r e n t
o f f i ce rs , d i r ec to rs , t r us tees (whe the r i nd i v i d ua l s o r o rgan i za t i ons ) , r ega rd l ess o f am oun t o f com pensa t i on .
E n t e r -0- I n co l um n s (D) , (E ), and (F) if no com pens a t i on was
pa id .
Lista l l o f the o rga n i za t i on ' s c u r r e n t key em p loye es , i f any . See i ns t ruc t i ons fo r d e f i n i t ion o f " key e m p loye e . "
List the organization 's five
current
highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable
compensation
(Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations.
Us t a ll o f the o rgan i za t i on ' s
f o r m e r
o f f i c e rs , k e y e m p l o y e e s , a n d h i g h e s t c o m p e n s a t e d e m p l o y e e s w h o r e c e i v e d m o r e t h a n $100,000 o f
reportable com pensa t i on f r om the o rgan i za t i on and any re l a ted o rgan i za t i ons .
Us t a l l o f the o rgan i za t i on ' s
f o r m e r d i r e c t o r s o r t r u s t e e s
t ha t r ece i ved , i n the cap ac i t y as a fo rm e r d i r ec to r o r t r us tee o f the o rgan i za t i on ,
more t h a n $10,000 o f r epo r tab l e com pensa t i on f r om the o rgan i za t i on and any re l a ted o rgan i za t i ons .
List pe rson s i n the fo l l ow ing o rd e r : i nd i v i d ua l t r us tee s o r d i r ec to rs ; i n s t i tu t i ona l t r us tee s ; o f f i ce rs ; key em p loye es ; h i ghes t com p ens a ted em p loyees ;
an d fom ne r such pe rsons .
I I Che ck th i s box if ne i the r the o rgan i za t i on no r any re l a ted o rgan i za t i on com pen sa te d any cu ne n t o f f i ce r , d i r ec to r , o r t r us tee .
(A)
Name
and Ti t le
(B)
Average
hou rs pe r
week
(list any
hou rs fo r
related
organ i za t i ons
below
l ine)
(C)
Position
(do no t
c h e c k
more than one
box, un l es s
p e r s o n i sboth an
officer
and a
d l rec tor / tn js tee)
(D)
Reportable
compensation
f r o m
the
organization
(W-2 /1099 -MISC)
(E)
Reportable
compensation
f r om re l a ted
o rgan i za t i ons
(W-2 /1099 -MISC)
(F)
Estimated
amount o f
o the r
compensation
f r om the
organization
an d re la ted
o rgan i za t i ons
(1 ) MATT BENJ AMIN
BOARD MEMBER
1.00
X 0.
0.
0
( 2 ) M I K E C O R B I N
BOARD MEMBER
1.00
0.
0.
( 3 ) R I C H KELBER
BOARD MEMBER
1.00
0. 0.
-0,
OJ
_0,
_0,
0
( 4 ) MATT LOKAN
BOARD
MEMBER
1.00
X
0.
( 5 ) DON MCPHERSON
BOARD P RES IDENT
2.00
X X 0.
( 6 ) DAVE OKADA
BOARD MEMBER
1.00
0.
( 7 ) SUSAN THOMPSON
BOARD MEMBER
1.00
0.
(8 ) SARAH CAVAZOS
EXECUTIVE D IRECTOR
4 0 . 0 0
X
5 2 , 8 2 2 0.
232007 12-10-12
F orm
99
(201
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
10/21
F orm 990 (2012 )
MID
V A L L E Y
MENTORS
2 0 - 5 5 3 1 2 3 7 Page S
(A)
Name
and t i t le
(B)
Average
hou rs pe r
week
(list any
h o u r s
for
related
organ i za t i ons
below
l ine)
(C)
Position
(do not c t ieck more than one
box, u n l e s s
person isboth an
officerand a d i rec tor / t rus tee)
(D)
Reportable
compensation
f r o m
the
organization
(W-2 /1099 -MISC)
(E)
Reportable
compensation
f r om re l a ted
o rgan i za t i ons
(W-2 /1099 -MISC)
(F)
Estimated
amount o f
o the r
compensation
f r om the
organization
an d
re la ted
o rgan i za t i ons
(A)
Name
and t i t le
(B)
Average
hou rs pe r
week
(list any
h o u r s
for
related
organ i za t i ons
below
l ine)
I
n
v
d
u
e
t
d
e
o
n
c;
o
1
K
e
e
m
p
o
l
g
e
c
m
p
e
e
m
p
o
s
e
S
(D)
Reportable
compensation
f r o m
the
organization
(W-2 /1099 -MISC)
(E)
Reportable
compensation
f r om re l a ted
o rgan i za t i ons
(W-2 /1099 -MISC)
(F)
Estimated
amount o f
o the r
compensation
f r om the
organization
an d
re la ted
o rgan i za t i ons
l b S u b - t o t a l
5 2 . 8 2 2 . 0. 0.
c
T o t a l from c o n t i n u a t i o n s h e e t s t o Par t V l l ,
S e c t i o n
A
d
To t a l ( add
l ines l b
a n d I c )
0. 0. 0.
T o t a l from c o n t i n u a t i o n s h e e t s t o Par t V l l ,
S e c t i o n
A
d
To t a l ( add
l ines l b
a n d I c )
5 2 . 8 2 2 . 0. 0.
2 To ta l num be r o f i nd i v i d ua l s ( in c l ud ing bu t no t lim i ted to those l i s ted above ) who rece i ved m ore than $100,000 o f r epo r tab l e
Y e s
No
3 D id the o rgan i za t i on l i s t any f o r m e r o f f i ce r , d i r ec to r , o r t r us tee , key em p loyee , o r h i ghes t com pensa ted em p loyee on
line la? If Yes, com plete Schedule J for such individual 3
X
4
For any ind iv id ua l l i s ted on l ine l a , i s the sum o f r epo r tab l e com pen sa t i o n and o the r com pen sa t i o n f r om the o rga n i za t i on
an d r e l a ted o rgan i za t i ons g rea te r than $150,000?
If Yes, complete Schedule J for such individual 4 X
5
Did any pers on l is ted on l ine
l a
r ece i ve o r accm e com pensa t i on f r om any un re l a ted o rgan i za t i on o r i nd i v i d ua l fo r se rv i ces
rendered
to the o roan i za t i on? if Yes,' compiete Schedule J for such person 5
X
S e c t i o nB . I n d e p e n d en t C o n t r a c t o r s
Complete t h i s tab l e fo r you r f i ve h i ghes t com pensa ted i nd epend en t con t rac to rs tha t r ece i ved m ore than $100,000 o f c o m p e n s a t i o n f r o m
(A)
Name a n d b u s i n e s s a d d r e s s NONE
(B)
Description o f serv ices
(C)
Compensation
2 To ta l num be r o f i nd e pend en t con t rac to rs ( Inc lud ing bu t no t l im i ted to thos e l i s ted above ) wh o rece i ved m ore than
$100,000
o f com pen sa t i o n f r om the o rqan i za t i on
0
232008
12-10-12
Fonn
99
(2012)
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
11/21
F orm 990 (2012 )
MID
V A L L E Y MENTORS
2 0 -5531237 P a g e 9
Pa r t V l l l S t a t e m e n t o f R e ve n u e
Check
i f Sc hed u le 0 con ta in s a resp ons e to any que st io n in th is Par t V l l l EZI
(A)
Total r evenue
(B)
Related o r
exempt f u n c t i o n
revenue
(C)
Unrelated
b u s i n e s s
revenue
Revenueexcluded
from tax under
sections 512,
513,
o r514
n
5 i
1 a F e d e r a t e d c a m p a i g n s
l a
b M e m b e r s h i p d u e s
l b
c
F und ra i s i ng even ts
I c 1 0 , 2 5 0 .
d Re la ted o rgan i za t i ons
I d
e Gov e rnm e n t g ran ts ( con t r i bu t i ons )
f
Al l other contr ibutions, gifts, grants, and
similar amounts not included above
l e 1 5 8 , 4 0 3 .
Gove rnm en t g ran ts ( con t r i bu t i ons )
f
Al l other contr ibutions, gifts, grants, and
similar amounts not included above
If
7 0 . 9 1 1 .
g N o n c a s h
cont r ibut ions inc luded in
l i nes
1a-1f:
3 0 1 6 6
h T o t a l . A d d l in e s 1a-1f
2 3 9 . 5 6 4
8
Eg
y
p
B u s i n e s s C o d e
2 a
b
c
d
e
f
a .
All
o the r p rog ram se rv i ce revenue
To ta l . Ad d l i nes 2a -2 f
3
OC
I
o
4
5
6
a
b
c
d
7
a
c
d
8
a
b
c
9 a
b
c
10a
b
c
Investment i n com e ( i nc l ud ing d i v i d end s , i n te res t , and
o the r s im il a r am oun ts )
Income f r om i nves tm e n t o f tax -exem p t bond p rocee d s
Roya l t i e s
G r o s s
ren ts
Less : r en ta l expenses
Rental i n c o m e o r Ooss)
Net ren ta l income or ( loss)
G ross am oun t f r om sa les o f
a s s e t s
o the r than Inven to ry
Less : cos t o r o the r bas i s
an d sa l es expenses
Gain or ( loss)
Net gain or ( loss)
G ross i ncom e f rom fund ra i s i ng even ts ( no t
including $ 1 0 , 2 5 0 . of
con t r i bu t i ons repo r ted on l i ne I c ) . See
Part IV, l ine 18 a
Less : d i r ec t expenses
b
Net i n co m e o r ( loss ) f r om fund ra i s i ng even ts
Gross i ncom e f rom gam ing ac t i v i t i e s . See
Part IV ,
line
19 a
L e s s : d i r e c t e x p e n s e s
b
Net
inco me or ( loss) f ro m gam ing act iv i t ies . .
G ross sa l es o f i n ven to ry , l e ss re tu rns
an d a l l o w a n c e s
a
Less : cos t o f good s so l d
b
Net
incom e or ( loss) f rom sa les of inventorv . .
(QRea l
(II) Personal
(i)
Sec u r i t i e s
( l i ) o ther
4 , 1 7 9 .
3 . 2 1 3 .
9 6 6 . 9 6 6 .
M i s c e l l a n e o u s
Revenue
11 a
b
c
d
e
12
Ail o the r revenue
T o t a l . A d d l i n e s 11a-1I d
Total revenue.See instructions.
B u s i n e s s
C o d e
2 4 0 . 5 3 0 .
0^
9 6 6 .
232009
12-10-12
Form
9 90
(2012
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
12/21
F orm 990 (2012 )
MID
V A L L E Y MENTORS
2 0 -5531237 P a g e l O
P a r t
IX
I
S t a t e m e n t o f F u n c t i o n a l
E x p e n s e s
Section 501(c)(3) and 501(c)(4) orqanizations must complete all columns. A ll other organizations must complete column (A).
Check
i f Sche d u le 0 con ta i ns a respo nse to any ques t i on i n th i s P a r t IX
Do
not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part Vlii.
(A)
Total e x p e n s e s
P rog ram se rv i ce
e x p e n s e s
(C)
Management and
general e x p e n s e s
ndra isundraising
e x p e n s e s
1
Grants and other assistance to governments and
organizations
in the United States. See Part IV, line 21
2
G ran ts and o the r ass i s tance to Ind i v i d ua l s i n
th e
Un i ted Sta tes. See Par t IV , l ine 22
3 G r a n t s a n d o t h e r a s s i s t a n c e t o g o v e r n m e n t s ,
o rgan i za t i ons , and i nd i v i d ua l s ou ts i d e the
United S ta tes. See Par t IV , l ines
15
and 16
4
Bene f i t s pa id to o r fo r m em bers
5 Com pen sa t i on o f cu r ren t o f f i ce rs , d i r ec to rs ,
t r u s t e e s , a n d k e y e m p l o y e e s
6 Compe nsation not included above, to disqualified
persons (as defined under section 4958(f)(1)) and
persons
described in section 4958(c)(3)(B)
7
O the r sa l a r ies and wa ges
8 Pension plan accruals and contrib utions (include
section
401(k) and 403(b) employer co ntr ibutions)
9
O the r em p loyee bene f i t s
10 P ayro l l ta xe s
11
F ees fo r se rv i ces ( non -em p loyees ) :
a M a n a g e m e n t
b Lega l
c A c c o u n t i n g
d
L o b b y i n g
e Professional fundra ising services. See Part IV, line 17
f I n v e s t m e n t m a n a g e m e n t f e e s
g Oth er. ( If l ine 11g amount exceeds 10% of line 25,
column
(A) amount, list line
11g
expenses on Sch 0.)
12
A d v e r t i s i n g a n d p r o m o t i o n
13 O f f i c e e x p e n s e s
14
I n f o r m a t io n t e c h n o l o g y
15 Roya l t i e s
16
O c c u p a n c y
17 Trave l
18 P aym en ts o f t r ave l o r en te r ta i nm en t expense s
for any federa l , s ta te , or loca l publ ic o f f ic ia ls
19 C o n f e r e n c e s , c o n v e n t i o n s , a n d m e e t i n g s
20 I n te res t
21 P aym en ts to a f f i l ia tes
22 Dep rec ia t i on , d ep le t i on , and am or t i za t i on
23 I n su rance
24
Other expenses. Itemize expenses not covered
above. (List m iscellaneous expenses in line 24e. If l ine
24e amount exceeds 10% of line 25, column (A)
amou nt, list line 24e expenses on Schedule 0.) ....
a
MATERIALS & S U P P L I E S
b
MISC ELLA NEOUS
c
T R A I N I N G
d S T A F F DEVELOPMENT
e A l l o the r expen ses
25 Total functional expenses.Add lines 1 through 24e
8.000
5 9 , 8 5 9 .
1 2 2 . 6 1 3 .
1 1 . 1 5 1 .
1 8 , 9 0 8 .
1 . 0 0 0 .
4 , 2 7 5 .
2 , 7 1 6 .
1 . 5 9 6 .
3 6 , 5 2 6 .
5 . 0 5 6 .
6 5 .
6 . 0 8 0 .
4 , 8 0 3 .
1 . 0 4 7 .
7 8 4 .
1 0 0 .
2 8 4 . 5 7 9 .
8 , 0 0 0 .
4 7 , 6 4 6 . 1 2 , 2 1 3 .
1 2 2 . 6 1 3 .
1 0 , 4 0 5 .
1 8 . 7 5 8 .
1 . 0 0 0 .
2 . 7 5 3 .
3 7 1 .
4 8 0 .
3 4 , 1 1 2 .
4 , 8 6 9 .
6 . 0 8 0 .
4 , 7 8 6 .
9 7 8
7 8 4
1 0 0
2 6 3 , 7 3 5 .
7 4 6 .
1 5 0 .
1 , 5 2 2 .
2 . 3 4 5 .
1 , 1 1 6 .
2 . 4 1 4 .
1 8 7 .
6 5 .
1 7 .
6 9 .
2 0 , 8 4 4 . 0.
26
Jointcosts.Complete this line only If the organization
reported
in column (B) joint costs from a combined
educational campaign and fundraising solicitation.
C h e c k h e r e [IZl i f follow ing S O P 98-2
l A S C 958-7201
232010 12-10-12
F orm
99
(2012)
-
8/11/2019 Mid Valley Mentors 2012 Charity Report
13/21
F o r m
990 (2012 )
MID
V A L L E Y
MENTORS
2 0 - 5 5 3 1 2 3 7 Paqe11
Pa r t X I
B a l a n c e
S h e e t
(A)
Beginning o f year
(B)
End
o f year
1
Cash n on - i n te res t - bea r i ng
5 4 , 6 8 7 .
1
4 2 . 9 6 0 .
2
S a v i n g s
a n d t e m p o r a r y c a s h i n v e s t m e n t s
2
3
P led ges and g ran ts rece i vab le , ne t
3
4
A c c o u n t s r e c e i v a bl e , n e t
3 8 . 7 6 2 .
4
1 3 , 4 3 4 .
5
Loans and o the r rece i vab les f r om cu r ren t and fonne r o f f i ce rs , d i r ec to rs ,
t m s t e e s , k e y e m p l o y e e s , a n d h i g h es t c o m p e n s a t e d e m p l o y e e s . C o m p l e t e
Part I I o f Sched u le L
5
6
Loans and o the r rece i vab les f r om o the r d i squa l i f i ed pe rsons (as d e f i ned und e r
section 4958 ( f )( 1 ) ) , pe rson s d esc r i bed i n sec t i on 4958 (c ) (3 ) (B ), and con t r i b u t i ng
e m p l o y e r s a n d sponsoring o rgan i za t i ons o f sec t i on 501 (c )(9 ) vo l un ta ry
em o love es ' bene f i c i a r y o rqan i za t i ons ( see ins t r ) . Com p le te P a r t I I o f Sch L
6
7
Notes and l oans rece i vab le , ne t
7
1
8
I n ven to r i es fo r sa l e o r use
8
9
Prepaid
e xpenses and d e fe r red cha rges
7 7 5 .
9
1 0 a
Land , bu i l d i ngs , and equ ipm en t : cos t o r o the r
bas i s . Com p le te P a r t V I o f Sched u le D
10a
b
L e s s : a c c u m u l a t e d d e p r e c i a t i o n
10b
10c
11
I n ve s tm en ts - oub l i c l v t r ad ed secu r i t i e s
11
12
I n ves tm en ts o the r secu r i t i e s . See P a r t IV, l ine 11
12
13
I n ve s tm e n ts - o roo ram - re l a te d . See P a r t IV , line 11
13
14
Intangible a s s e t s
14
15
Other assets. See Par t IV , l ine 11
15
16
Total
a s s e t s .
Ad d l i nes 1 th rouqh 15 (must equa l l ine 34)
9 4 . 2 2 4 .
16
5 6 . 3 9 4 .
17
A c c o u n t s p a y a b l e a n d a c c m e d e x p e n s e s
6 . 9 4 3 . 17
1 3 , 1 6 2 .
18
G r a n t s p a y a b l e
18
19
Defen-ed r evenue
19
20
Tax-exemot bond l iab i l i t ies
20
21
Escrow o r cus tod ia l acco un t l i ab i li t y . Com p le te P a r t IV o f Sched u le D
21
22
L o a n s
and o the r payab les to cunen t and fo rm e r o f f i ce rs , d i r ec to rs , tm s tees .
o
key e m p l o y e e s , h i g h e s t c o m p e n s a t e d e m p l o y e e s , a n d d i s q u a li f ie d p e r s o n s .
Complete
Par t I I o f Sche du le L
22
23
Secured m or tgages and no tes payab le to un re l a ted th i r d pa r t i e s
23
24
Unsecured no tes and l oans payab le to un re l a ted th i r d pa r t i e s
24
25
Other l iab i l i t ies ( Inc lud ing federa l income tax, payables to re la ted th i rd
par t ies, and other l iab i l i t ies not inc luded on l ines 17-24) . Comple te Par t X of
Schedule D
25
26
Total l i ab i l i t i es . Ad d l i nes 17 t h rough 25
6 . 9 4 3 . 26
1 3 . 1 6 2 .
O r g a n i z a t i o n sthat
follow S F A S
117 ( A S C 95 8 ),
c h e c k
h e r e
1
X
1 and
to
o
c
27
complete l i n e s 27 t h r ough 29 , and l ines 33 and 34 .
Unrestricted ne t asse ts
3 2 , 7 7 3 . 27
3 3 . 6 1 4 .
(S
IS
28
Temporarily r es t r i c ted ne t asse ts
5 4 . 5 0 8 . 28
9 . 6 1 8 .
OQ
O
29
P erm anen t i v r es t r i c ted ne t asse ts
29
c
3
l i .
29
O r g a n i z a t i o n sthat d o n o t
follow S F A S
117( A S C 9 5 8 ), c h e c k h e r e C D
w
o
a n d c o m p l e t e l i n e s 30 t h r ough 34 .
(0
+-I
30
Caoital s toc k o r tm s t o r i nc i oa l , o r cun -en t fund s
30
Q)
l
10
31
Paid-in
o r cap i ta l su rp l us , o r l and , bu i l d i ng , o r equ ipm e n t fun d
31