#ILLINOIS CHARITABLE ORGANIZATION ANNUAL REPORT Form AG990-ILRevised / YesNo LEGALNAMEMAIL A)ASSETSA)$ADDRESS B)LIABILITIESB)$CITY, STATEC)NET ASSETSZIP CODE C)$ PERCENTAGE AMOUNT % D)$ % E)$ % F)$ 100% G)$ I.SUMMARY OF ALL REVENUE ITEMS DURING THE YEAR:F)OTHER REVENUESG)TOTAL REVENUE, INCOME AND CONTRIBUTIONS RECEIVED (ADD D,E, & F)II.SUMMARY OF ALL EXPENDITURES DURING THE YEAR:K)GRANTS TO OTHER CHARITABLE ORGANIZATIONSN)FUNDRAISING EXPENSEO)TOTAL EXPENDITURES THIS PERIOD (ADD L, M, & N)D)PUBLIC SUPPORT, CONTRIBUTIONS & PROGRAM SERVICE REV. (GROSS AMTS.)E)GOVERNMENT GRANTS & MEMBERSHIP DUESH)OPERATING CHARITABLE PROGRAM EXPENSEI)EDUCATION PROGRAM SERVICE EXPENSEL)TOTAL CHARITABLE PROGRAM SERVICE EXPENDITURE (ADD J & K)M)MANAGEMENT AND GENERAL EXPENSE 100 % P)$ % Q)$ % R)$III.SUMMARY OF ALL PAID FUNDRAISER AND CONSULTANT ACTIVITIES:(Attach Attorney General Report of Individual Fundraising Campaign- Form IFC. One for each PFR.)P)TOTAL AMOUNT RAISED BY PAID PROFESSIONAL FUNDRAISERSQ)TOTAL FUNDRAISERS FEES AND EXPENSESR)NET RECEIVED BY THE CHARITY (P MINUS Q=R) T)$IV.COMPENSATION TO THE (3) HIGHEST PAID PERSONS DURING THE YEAR:T)NAME, TITLE: U)$ V)NAME, TITLE: V)$ CODE W)#V.CHARITABLE PROGRAM DESCRIPTION: X)DESCRIPTION: X)# Y )DESCRIPTION: Y)# CO Attorney GeneralState of Illinois Charitable Trust Bureau, 100 West Randolph11th Floor, Chicago, Illinois 60601Year-end amountsCheck all items attached: For Office Use Only W)DESCRIPTION:CHARITABLE PROGRAM (3 HIGHEST BY $ EXPENDED) CODE CATEGORIESList on back side of instructionsS)TOTAL AMOUNT PAID TO PROFESSIONAL FUNDRAISING CONSULTANTS / / / / N)$O)$L)$M)$100 %%% % K)$ % H)$ S)$ Make Checks Payable to the Illinois Charity Bureau FundMO DAY YRMO DAY YRAre contributions to the organization tax deductible? Copy of IRS ReturnAudited Financial StatementsCopy of Form IFC$15.00 Annual Report Filing Fee$100.00 Late Report Filing FeeReport for the Fiscal Period:BeginningFederal ID #& Ending / / Date Organization was created: U)NAME, TITLE:PMT #AMTINIT % I)$J)TOTAL CHARITABLE PROGRAM SERVICE EXPENSE (ADD H & I)J1) JOINT COSTS ALLOCATED TO PROGRAM SERVICES (INCLUDED IN J): $ % J)$% PROFESSIONAL FUNDRAISERS: PROFESSIONAL FUNDRAISING CONSULTANTS: American LegalNet, Inc. www.FormsWorkFlow.com ALL ATTACHMENTS MUST ACCOMPANY THIS REPORT - SEE INSTRUCTIONS UNDER PENALTY OF PERJURY, I (WE) THE UNDERSIGNED DECLARE AND CERTIFY THAT I (WE) HAVE EXAMINED THIS ANNUAL REPORT AND THE ATTACHED DOCUMENTS, INCLUDING ALL THE SCHEDULES AND STATEMENTS, AND THE FACTS THEREIN STATED ARE TRUE AND COMPLETE AND FILED WITH THE ILLINOIS ATTORNEY GENERAL FOR THE PURPOSE OF HAVING THE PEOPLE OF THE STATE OF ILLINOIS RELY THEREUPON. I HEREBY FURTHER AUTHORIZE AND AGREE TO SUBMIT MYSELF AND THE REGISTRANT HEREBY TO THE JURISDICTION OF THE STATE OF ILLINOIS. BE SURE TO INCLUDE ALL FEES DUE: PRESIDENT or TRUSTEE (PRINT NAME) SIGNATURE DATE 1.) REPORTS ARE DUE WITHIN SIX MONTHS OF YOUR FISCAL YEAR END. 2.) FOR FEES DUE SEE INSTRUCTIONS. TREASURER or TRUSTEE (PRINT NAME) SIGNATURE DATE 3.) REPORTS THAT ARE LATE OR INCOMPLETE ARE SUBJECT TO A $100.00 PENALTY. PREPARER (PRINT NAME) SIGNATURE DATE 6. ( ATTACH FORM I FC ) 6. DID THE ORGANIZATION USE THE SERVICES OF A PROFESSIONAL FUNDRAISER? 7. 7a. DID THE ORGANIZATION ALLOCATE THE COST OF ANY SOLICITATION, MAILING, ADVERTISEMENT OR LITERATURE COSTS BETWEEN PROGRAM SERVICE AND FUNDRAISING EXPENSES? 8. 9. SUSPENDED OR REVOKED BY ANY GOVERNMENTAL AGENCY? 10. IF THE ANSWER TO ANY OF THE FOLLOWING IS YES, ATTACH A DETAILED EXPLANATION: 1. WAS THE ORGANIZATION THE SUBJECT OF ANY COURT AC TION, FINE, PENALTY OR JUDGMENT? 1. 2 . HAS THE ORGANIZATION OR A CURRENT DIRECTOR, TRUSTEE, OFFICER OR EMPLOYEE THEREOF, EVER BEEN CO NVICTED BY ANY COURT OF ANY MIS DEMEANOR INVOLVING THE MISUSE OR MISAPPROPRIATION OF FUNDS OR ANY FELONY? 2 3. DID THE ORGANIZATION MA KE A GRANT AWARD OR CONTRIBTION TO ANY ORGANIZATION IN WHICH ANY OF ITS OFFICERS, DIRECTORS OR TRUSTEES OWNS AN INTEREST; OR WAS IT A PARTY TO ANY TRANSACTION IN WHICH ANY OF ITS OFFICERS, DI RECTORS OR TRUSTEES HAS A MATERIAL FINANCIAL INTEREST; OR DID ANY OFFICER, DIRECTOR OR TRUSTEE RECEIVE ANYTHING OF VALUE NOT REPORTED AS COMPENSATION? 3. 4 . HAS THE ORGANIZATION INVESTED IN ANY CORPORATE STOCK IN WHICH ANY OFFICER, DIRECTOR OR TRUSTEE OWNS MORE THAN 10% OF THE OUTSTANDING SHARES? 4. 5. IS ANY PROPERTY OF THE ORGANIZATION HELD IN THE NAME OF OR COMMINGLED WITH THE PROPERTY OF ANY OTHER PERSON OR ORGANIZATION? 5. 7b. IF "YES", ENTER (i) THE AGGREGATE AMOUNT OF THESE JOINT COSTS $ ;(ii) THE AMOUNT ALLOCATED TO PROGRAM SERVICES $ ; (iii) THE AMOUNT ALLOCATED TO MANAGEMENT AND GENERAL $ ; AND (iv) THE AMOUNT ALLOCATED TO FUNDRAISING $ 8. DID THE ORGANIZATION EXPEND ITS RESTRICTED FUNDS FOR PURPOSES OTHER THAN RESTRICTED PURPOSES ? 9. HAS THE ORGANIZATION EVER BEEN REFUSED REGISTRATION OR HAD ITS REGISTRATION OR TAX EXEMPTION 10. WAS THERE OR DO YOU HAVE ANY KNOWLEDGE OF ANY KICKBACK, BRIBE, O R ANY THEFT, DEFALCATION, MISAPPROPRIATION, COMMINGLING OR MISUSE OF ORGANIZATIONAL FUNDS? 11. LIST THE NAME AND ADDRESS OF THE FINANCIAL INSTITUTIONS WHERE THE ORGANIZATION MAINTAINS ITS THREE LARGEST ACCOUNTS: 12. NAME AND TELEPHONE NUMBER OF CONTACT PERSON: NO YES American LegalNet, Inc. www.FormsWorkFlow.com