Professional Documents
Culture Documents
990-EZ
Form
Check if applicable:
Name change
Initial return
Terminated
2010
Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities,
and certain controlling organizations as defined in section 512(b)(13) must file
Form 990 (see instructions). All other organizations with gross receipts less than $200,000
and total assets less than $500,000 at the end of the year may use this form.
^ The organization may have to use a copy of this return to satisfy state reporting
requirements.
Address change
0 M B No. 1545-1150
OpjBn to;Publlc
inspectlon;:''''r,*'
Telephone number
23-7227328
831-626-1681
Amended return
F Group Exemption
Number.
Application pending
G
I
Accounting Method:
Website:
WWW.
X Cash
[_J Accrual
Other (specify)
J
K
Add lines 5b 6c, and 7b, to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total
assets (Part II, line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ
f o r e s t ^ e a t e r q u i l d . org
Check
if the organization is not
required to attach Schedule B (Form
990, 990-EZ, or 990-PF).
$
97,161.
[PartJJ Revenue, Expenses, and Changes in Net Assets or Fund Balances (See the instructions for Part 1.)
Check If the organization used Schedule 0 to respond to any question in this Part I
1
2
Investment income
35,658.
61,503.
5a
5b
Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a)
5c
6a
of contributions
6b
6c
Net income or (loss) from gaming and fundraising events (add lines 6a and
6b and subtract line 6c)
7 a Gross sales of inventory, less returns and allowances
6d
7a
- f.^
7b
c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a).
^Ofi
7c
97,161.
10
11
12
13
14
15
16
17
18
19
Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end-of-vear
figure reported on prior year's return)
^
20
21
Net assets or fund balances at end of year. Combine lines 18 through 20.
12.
11
21.
Jll.
14
.See..Schedule. Q .
BAA For Paperwork Reduction Act Notice, see the separate instructions.
TEEA0803L
02/10/11
21.
18
109,750.
109,750.
-12,589.
19
15,744.
16
17
20
21
3,155.
Form 990-EZ (2010)
23-7227328
Page
22
23
24
25
15,744.
15,744. 25
0, 26
15,744, 27
3,155.
24
Net assets or fund balances (line 27 of column (B) must agree with line 21) .
Part III
23
22
3,155.
0.
3,155.
Expenses
(Required for section
501 (c)(3) and 501 (c)(4)
organizations and section
4947(;a)(1) trusts; optional
for others.)
Sae_Schedul_a.
(Grants $
28 a
(Grants $
29 a
(Grants $
) If this amount includes foreign grants, check here .
Other program services (describe in Schedule O ) .
30 a
(Grants $
) If this amount includes foreign grants, check here .
Total
rogram
service
expenses
(add
lines 28a through 31a)
^
.
31a
32
29
30
31
32
List each one even if not compensated, (see the instructions for Part IV.
Check if the organization used Schedule O to respond to any question in this Part IV.
fa
(b) Title and average hours (c) Compensation (If
(d) Contributions to
(e) Expense account
(a) Name and address
per week devoted
not paid, enter -0-.) employee benefit plans and and other allowances
to position
deferred compensation
J M B J ^
MOSSBERG
_Pp_BpX_9_7
C A R M E L , CA 93921
_Pp_B_OX_5_596
C A R M E L , C A 93921 "
_CRYS_TAL H O N N
_ S M _ C M L P S _& 5TH
C A R M E L , CA 93921
_BRI^M_GROSSI
_3 012_ C O M O M N T _ R 0 ^
P E B B L E B E A C H , CA 93953"
W I L L J M _BJRCH_
_Pp_B_pX_2_325
C a r m e l , CA 93921
JAEmT_MALEK
_Pp_B_pX_l_734
P E B B L E B E A C H , C A 93953"
jJEFFJ^Y J H O M P S O N
J - l i . J J D _yAL];Y_(;ENTro_ _
C a r m e l V a l l e y , CA 93924
_jpAMA_TOP^_
_PP_^X_7_342
C A R M E L , C A 93921
J^I ITH_ DE_CKE^R
_L I G H T H O U S E
P A C I F I C G R O V E , CA 93950
_LEI^GH_GI^Y
_4 0 3 jP3JNI_PER(^ A V ^
P A C I F I C G R O V E , CA 93950
Vice President
0
0.
0.
President
Secretary
0.
Trustee
0
t ;
Treasurer
0
"0:
Trustee
0
"0:
Trustee
0
Trustee
0
'V.
Trustee
0
Trustee
0
TEEA0812L
02/18/11
T.
Form
990-EZ
(2010)
23-7227328
Party I Other Information (Note the statement requirements in tlie instructions for Part V.)
Page 3
See Schedule 0
Check if the organization used Schedule 0 to respond to any question in this Part V
33
Yes
Did the organization engage in any activity not previously reported to the IRS? If 'Yes,' provide a detailed description of
each activity in Schedule 0
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 0 (see instructions)
34
35
If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but not reported on Form 990-T,
explain in Schedule 0 why the organization did not report the income on Form 990-T.
36
a Did the organization have unrelated business gross income of $1,000 or more or was it a section 501(c)(4), 501(c)(5), or
501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements?
35a
b If 'Yes,' has it filed a tax return on Form 990-T for this year (see instructions)?
35 b
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
37a Enter amount of political expenditures, direct or indirect, as described in the instructions,
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?
39
36
37 b
38 a
38b
N/A
39 a
N/A
N/A
39 b
4 0 a Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
section 4911
0 ^ ; section 4912
0 . ; section 4955
0 .
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
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
42 a The organization's
books are in care of
Located at
0 _
None
Jlebecca J a r r y m o : ^
40 e
0.
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
List the states with which a copy of this return is tiled
40 b
0.
d Section 501 (c)(3) and 501 (c)(4) organizations. Enter amount of tax on line 40c reimbursed
by the organization
41
JL
0.
37a I
No
Telephoneno. - _ 8 3 1 - _ 6 2 6 - _ 1 6 8 : i ^
ZIP-t-A" 93921
232_5^ _Carmel_j^
b At any time during the calendar year, did the organization have an interest in or a signature or other authority over a
financial account in a foreign country (such as a bank account, securities account, or other financial account)?
Yes
No
42 b
42c
~X
See the instructions for exceptions and filing requirements for Form I D F 90-22.1, Report of a Foreign Bank and Financial Accounts.
c At any time during the calendar year, did the organization maintain an office outside of the U.S.?
If 'Yes,' enter the name of the foreign country:..
43
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041 - Check here
and enter the amount of tax-exempt interest received or accrued during the tax year
^ ^ S Fom990-E?''"
N/A
N/A
43
44b
X
X
TEEA0812L
02/18/11
44c
an explanation
No
44a
hospital facilities during the year? If 'Yes,' Form 990 must be completed
c Did the organization receive any payments for indoor tanning services during the year?
Uhedule
Yes
in
44d
Form 990-EZ (2010)
23-7227328
Page'
Yes
45
Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)?
a 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-E2 (see Inst.)
46
45 a
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to
candidates for public office? If 'Yes,' complete Schedule C, Part f
Part VI
No
45
46
Section 501 (cX3) organizations and section 4947(aXl) nonexempt charitable trusts only. A I section
501(c)(3) organizations and section 4947(a)(1) nonexempt ciiaritabie trusts must answer questions
47-49b and 52, and complete tine tables for lines 50 and 51.
Check if the organization used Schedule O to respond to any question in this Part VI
Yes
47
Did the organization engage in lobbying activities? If 'Yes,' complete Schedule C, Part II
47
48
48
49a Did the organization make any transfers to an exempt non-charitable related organization?
49 a
No
X
X
X
49 b
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key
employees) who each received more than $100,000 of compensation from the organization. If there is none, enter 'None.'
50
(c) Connpensation
(e) Expense
account and
other allowances
None
Complete this table for the organization's five highest compensated independent contractors who each received more than $100 000 of
compensation from the organization. If there is none, enter 'None.'
, v v^i
(a) Name and address of each independent contractor paid more than $100,000
(c) Compensation
None
X
--.IMK.CIC
Sign
Here
Date
No
^.leparer ^ul^le^ man onicer; is paseg on an intormalion of which preparer has any knowledge
Signature of officer
Yes
Preparer's signature
Date
J. Daniel Clarke
Paid
J. Daniel Clarke
Preparer F i r m s name J . D a n i e l C l a r k e
Use Only F i r m s address
280 R e e s i d e A v e
M o n t e r e y , CA 93940
May the IRb discuss this return with the preparer shown above? See instructinn<;
BAA
TEEA0812L
02/18/11
9/13/11
Check
if
self-employed
Firm's EIN
Phone no.
PTIN
N/A
N/A
375-6230
|X| Yes n No
( 8 3 1 )
SCHEDULE A
2010
Open.to Public
Inspection,
A medical research organization operated in conjunction with a hospital described in section 170(bX1XAXiii)- Enter the hospital's
name, city, and state:
An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section
170(bX1XAXiv). (Complete Part II.)
An organization organized and operated exclusively to test for public safety. See section 509(aX4).
11
An organization organized and operated exclusively for the benefit of, to perform the functions of, or carry out the purposes of one or
more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(aX3). Check the box that
descnbes the type of supporting organization and complete lines l i e through l l h .
a Qlype I
b Q l y p e II
d Q
[_J By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons
other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or
section 509(a)(2).
If the organization received a written determination from the IRS that is a Type I, Type II or Type III supporting organization,
checkk1 tnis DOX
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i)
(ii)
(iii)
A person who directly or indirectly controls, either alone or together with persons described in (ii) and (iii)
below, the governing body of the supported organization?
A family member of a person described in (i) above?
(11) EIN
(iv) Is the
organization in
column (1) listed in
your governing
document?
Yes
(A)
(B)
(C)
(D)
(E)
Total
D A
r . . D . ^ . .
1.
n . J . . - ^ ; -
TEEA0401L
12/23/10
No
iig(i)
iig(ii)
11 g (iii)
Yes
No
Yes
No
(vi) Is the
organization in
column (!)
organized in the
U.S.?
Yes
No
23-7227328
Page 2
Part II I Support Schedule for Organizations Described in Sections 170(bX1XAXiv) and 170(bX1XAXvi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part
organization fails to qualify under the tests listed below, please complete Part III.)
If the
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(f) Total
V
t
. . ..
(e)2010
(a) 2006
(b) 2007
(c) 2008
(d) 2009
1 i
(e)2010
(f) Total
10
11
12
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3)
organization, check this box and stop here
^
'
12
Public support percentage for 2010 (line 6, column (f) divided by line 11, column (f)).
15
14
15
a n H O r g a n i s a t i o n
did not check the box on line 13, and the line 14 is 33-1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
V
^
H
"
o.^anization did not check a box on line 13 or 16a, and line 15 is 33-1/3% or more, check this box
^
and stop here. The organization qualifies as a publicly supported organization
^
r,
17a 10%-facts-and-circumstances test - 2010. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10%
or more, and if the organization meets the 'facts-and-circumstances' test, check this box and stop here. Explain in Part IV how
the organization meets the 'facts-and-circumstances' test. The organization qualifies as a publicly supported o ganizat on
n?mnfp
^
Organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10%
n nStfon mirfJhf
the 'facts-and-circumstances' test, check this box and stop here. Explain in Part IV how the
organization meets the facts-and-circumstances' test. The organization qualifies as a publicly supported organization
Private foundation. If the organization did not check a box on line 13, 16a. 16b, 17a, or 17b, check this box and see instructions.
BAA
TEEA0402L 12/23/10
^ 1 ^ ^
(Complete only if you checked the box on line 9 of Part 1 or if the organization failed to qualify under Part II. If the organization fails
to qualify under the tests listed below, please complete Part II.)
(a) 2006
(b) 2007
(c) 2008
135,410.
121,309.
142,188.
64,437.
35,658.
499,002.
206,052.
285,329.
255,752.
22,392.
61,503.
831,028.
(d) 2009
(e)2010
( 0 Total
0.
0.
341,462.
406,638.
397,940.
86,829.
97,161.
0.
1,330,030.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
- "
(a) 2006
(b) 2007
(c) 2008
341,462.
406,638.
397,940.
(d) 2009
(e)2010
86,829.
1,330,030.
( 0 Total
97,161.
1,330,030.
0.
0.
0.
0.
0.
0.
0.
0.
0.
12
13
14
341,462.
406,638.
397,940.
86,829.
97,161.
0.
1,330,030.
Public support percentage for 2010 (line 8, column (f) divided by line 13, column (f)).
16
Investment income percentage for 2010 (line 10c, column (f) divided by line 13, column (f))
18
16
100.0 %
100.0 %
17
0.0 %
15
0.0 %
18
ftnnf^^r'i^i^hln
'J It? o/sanization did not check the box on line 14, and line 15 is more than 33-1/3%, and line 17
IS not more than 33-1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
TEEA0403L 12/29/10
23-7227328
Page4
Part ly I Supplemental Information. Complete this part to provide the explanations required by Part II, line 10;
Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information.
(See instructions).
BAA
09/08/10
SCHEDULE 0
2010
Open to Public
Inspection
23-7227328
. - F o r m 990:LEj:^Paji_l!l - _ Q r 5 a n i z a t i o n 3 _ P r i m a j y _ E x e m p t ^ ^ ^
. c o m m u n i t y edu^ay_pnal_ se^ryice
. -FpJini ??Pi.EZi.Pa_rtJ!Li-Lne 28 -_St.tement pf_Prqgra^tti Se^rvice AccpmBlishments
.
Jiroc^cUoris i)f
J o r _10 ,_q00 _ti)_12_, Oq^O_ p e o p l e in_the jqommujii^_ fo^r_ a_p^riod_q^f_ 14 _t:o _1_8_
w i y i _ the_ p a r t i c ^ i p a t i ^ n _ o _ f _ l o _ c a l j c h 0 j ) l s
in_the
_Pi:oduction_q^f
_indirectly^
No
cor^ra^c_t?._
B A A For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
No
TEEA4901L
10/26/1 O
2010
Page 2
23-7227328
Total $
2,016.
1,964.
550.
4,050.
3,598.
1,674.
300.
2,000.
4,500.
926.
1,264.
905.
271.
50.
2,100.
2,116.
-875.
2,450.
3,050.
881.
1,576.
18,962.
2,000.
617.
936.
2,266.
964.
844.
316.
1,812.
11,561.
1,500.
2,333.
560.
9,711.
2,000.
1,178.
2,000.
11,130.
88.
1,906.
500.
1,200.
109,750.
Form
8868
If you are filing for an Automatic 3-IVlonth Extension, complete only Part I and check this box.
If you are filing for an Additional (Not Automatic) 3-IVIonth Extension, complete only Part II (on page 2 of this form).
Do not complete PartII unlessyou have already been granted an automatic 3-month extension on a previously filed Form 8868.
Electronic filing (e-file). You can electronically file Form 8868 if you need a 3-month automatic extension of time to file (6 months for a
corporation required to file Form 990-T), or an additional (not automatic) 3-month extension of time. You can electronically file Form 8868 to
request an extension of time to file any of the forms listed in Part I or Part II with the exception of Form 8870, Information Return for Transfers
Associated With Certain Personal Benefit Contracts, which must be sent to the IRS in paper format (see instructions). For more details on the
electronic filing of this form, visit www.irs.gov/efile and click on e-file for Charities & Nonprofits.
Part 1 I Automatic 3-IVIonth Extension of Time. Only submit original (no copies needed).
A corporation required to file Form 990-T and requesting an automatic 6-month extension - check this box and complete Part I only
All other corporations (Including 1120-C filers), partnerships, REMICS, and trusts must use Form 7004 to request an extension of time to file
income tax returns.
Type or
print
File by the
due date for
filing your
return. See
instructions.
23-7227328
Number, street, and room or suite number. If a P.O. box, see Instructions.
P . O . B o x 2325
city, town or post office, state, and ZIP code. For a foreign address, see instructions.
C a m e l , CA 93921
Enter the Return code for the return that this application is for (file a separate application for each return)
[W
Application
Is For
Return
Code
Return
Code
Application
Is For
Form 990
01
Form 990-BL
07
02
Form 1041-A
Form 990-EZ
Form 990-PF
08
03
Form 4720
09
04
Form 5227
05
Form 6069
10
11
06
Form 8870
12
J^ebecca
Jiarrymor^
If the organization does not have an office or place of business in the United States, check this box.
If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN)
If this is for the whole group.
check this box. . [ ] . If it is for part of the group, check this box.
Q and attach a list with the names and EINs of all members
^the extension is for.
1
I request an automatic 3-month (6 months for a corporation required to file Form 990-T) extension of time
until _ 8 / l _ 5
, 2 0 _ 1 1 _ , to file the exempt organization return for the organization named above.
The extension is for the organization's return for:
X calendar year 20 1 0
tax year beginning
or
,20
, and ending
If the tax year entered in line 1 is for less than 12 months, check reason:
I Change in accounting period
,20
Q Initial return
Final return
3a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any
nonrefundable credits. See instructions
^
b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax
payments made. Include any prior year overpayment allowed as a credit
i l l ^ n c e due. Subtract line 3b from line 3a. Include your payment with this form, if required, by using
EFTPS (Electronic Federal Tax Payment System). See insti^uctions
,
S e n t
ins^t?uctlons'"^
3a
0.
3b
0.
0.
electronic fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO for
11/15/10
Page 2
Type or
print
Number, street, and room or suite number. If a P.O. box, see instructions.
File by the
extended
due date for
filing the
return. See
instructions.
J . Daniel Clarke
280 Reeside A v e .
City, town or post office, state, and ZiP code. For a foreign address, see instructions.
M o n t e r e y , CA 93940
Enter the Return code for the return that this application is for (file a separate application for each return)
Application
Is For
Return
Code
03
Application
Is For
Return
Code
Form 990
01
Form 990-BL
02
Form 1041 -A
08
Form 990-EZ
03
Form 4720
09
Form 990-PF
04
Form 5227
10
05
Form 6069
11
-V
06
Form 8870
STOP! Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868,
The books are in care of. ^ J ^ e b ^ c a
12
_Barr3Tno^_
If the organization does not have an office or place of business in the United States, check this box.
If this is for a Group Return, e n ^ the organization's four digit Group Exemption Number (GEN),
whole group, check this box . . .
, 20 _ 1 1 .
,20
If the tax year entered in line 5 is for less than 12 months, check reason:
_ , and ending
, 20
Final return
Initial return
resj)ec1^fui:i^_regue^ts_^di^
return.
8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any
nonrefundable credits. See instructions
8a S
b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax
pa^:|ments made. Include any prior year overpayment allowed as a credit and any amount paid previously
Subtract line 8b from line 8a. Include your payment with this form, if required, by usinq
EFTPS (Electronic Federal Tax Payment System). See instructions
8b
8c
accompanying schedules and statements, and to the best of my knowledge and belief, it is true.
Signature
BAA
Titie
Date
FiFZ0502L
11/15/10