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990 Return of Organization Exempt From Income Tax OMB No. 1545 0047
Form
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung 2012
Department of the Treasury benefit trust or private foundation) i Open to Public
Internal Revenue Service ► The organization may have to use a copy of this return to satisfy state reporting requirements. , Inspection
B Check if applicable: C Name of organization
❑ Address change Doing Business As
❑ Name change Number and street (or P.O. box if mail is not delivered to street address)
❑ Initial return
❑ Terminated City, town or post office, state, and ZIP code
❑ Amended return
❑ Application pending F Name and address of principal officer:
Room/suite
I Tax-exempt status: U 501 U 501 ) ,4 ortserit no.) U 4047(aXII or U 527
J website: ►
K Form of oroaaization:n GomoraHnn n Trust n Assnciatinn I71 Other ► I L Year of fnrmatinn-
D Employer Identification number
E Telephone number
_LO Gross receipts $
His) Is this a group return for afriiates? ❑ Yes ❑ No
H(b) Are all affiliates included? ❑ Yes ❑ No
If "No," attach a list. (see instructions)
Hie) Group exemption number ►
M State of tenet dnmlcila-
■ j LJ &J b1gnaUU8 DIOCK
Under penalties of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign , Signature of officer Date
Here
Type or print name and title
Paid Print /type preparer's name Preparer's signature Date Check ❑ if PTIN
Preparer self-employed
Use Only Firm's name ► Firm's EIN ►
Firm's address ► Mom nn_
...-.r -.._ -- .- -'__ °- ....- . - --- - - .. --- ....- r....pF..w ............... -- %mow ......, .,.....v. wr . . . . . 1_I . .. V .
For Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 11282Y Form 990 (2012)
Summa
1
Briefly describe the organization's mission or most significant activities:
g------------------------------
-- -------------- ____-.-------- --- --- ---------------------------------------------------------------------------------
-- -------
2
- - -- ----- ••- ---- - -- -- - -- --- --- -- --- -__... -- _._----I---.--------- --- -- -- -- ---- ----- ----- '- ----- - -- - -- -rW-t- -- --- ---- - - - -- -I -----------------------------
Check this box ► ❑ if the organization discontinued its operations or disposed of more than 25'Ye of Its net assets.
3
Number of voting members of the governing body (Part VI, line 1 a) . . . .
. . . . . 3
4
Number of independent voting members of the governing body (Part VI, line 1 b) 4
5
Total number of individuals employed in calendar year 2012 (Part V, line 2a)
5
6
Total number of volunteers (estimate If necessary) . . . . . . . . .
. . . . . 6
7a
Total unrelated business revenue from Part VIII, column (C), line 12 . . .
. . . . . 7a
b
Net unrelated business taxable income from Form 990 -T, line 34
7b
Prior Year
Current Year
e
8
Contributions and grants (Part VIII, line 1h) . . . . . . . . . . . .
c
9
Program service revenue (Part VIII, line 2g) . . . . . . . . .
1
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d)
11
Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9C,10C, and 11 e) .
12
Total revenue —add lines 8 through 11 (must equal Part VIII, column (A), line 12)
13
Grants and similar amounts paid (Part IX, column (A), lines 1 -3) . . . . .
14
Benefits paid to or for members (Part IX, column (A), line 4) . . . . . .
15
Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10)
16a Professional fundralsing fees (Part IX, column (A), line 11 e) . . . . . .
b
Total fundraising expenses (Part IX, column (D), line 25) ►
t"
17 Other expenses ( Part IX, column (A), lines 11 a -11 d, 11 f -24e)
18
Total expenses. Add lines 13 -17 (must equal Part IX, column (A), line 25)
19
Revenue less expenses. Subtract line 18 from line 12
Beginning of Current Year
End of Year
20
Total assets (Part X, line 16)
IT
21
Total liabilities (Part X, line 26) . . . . *
LL
22 Net assets or fund balances. Subtract line 21 from line 20
■ j LJ &J b1gnaUU8 DIOCK
Under penalties of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign , Signature of officer Date
Here
Type or print name and title
Paid Print /type preparer's name Preparer's signature Date Check ❑ if PTIN
Preparer self-employed
Use Only Firm's name ► Firm's EIN ►
Firm's address ► Mom nn_
...-.r -.._ -- .- -'__ °- ....- . - --- - - .. --- ....- r....pF..w ............... -- %mow ......, .,.....v. wr . . . . . 1_I . .. V .
For Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 11282Y Form 990 (2012)