Fill a Valid Illinois Ag990 Form

Federal ID #

MO

DAY

YR

MO

DAY

YR

Date Organization was created:

/

/

Are contributions to the organization tax deductible?

Yes

No

LEGAL

Year-end

amounts

NAME

A) ASSETS

A) $

MAIL

ADDRESS

B) LIABILITIES

B) $

CITY, STATE

C) NET ASSETS

C) $

ZIP CODE

I. SUMMARY OF ALL REVENUE ITEMS DURING THE YEAR:

PERCENTAGE

AMOUNT

D) PUBLIC SUPPORT, CONTRIBUTIONS & PROGRAM SERVICE REV. (GROSS AMTS.)

%

D) $

E) GOVERNMENT GRANTS & MEMBERSHIP DUES

%

E) $

F) OTHER REVENUES

%

F) $

G) TOTAL REVENUE, INCOME AND CONTRIBUTIONS RECEIVED (ADD D,E, & F)

100%

G) $

0

II. SUMMARY OF ALL EXPENDITURES DURING THE YEAR:

H) OPERATING CHARITABLE PROGRAM EXPENSE

%

H) $

I) EDUCATION PROGRAM SERVICE EXPENSE

%

I) $

J) TOTAL CHARITABLE PROGRAM SERVICE EXPENSE (ADD H & I)

%

J) $

0

J1) JOINT COSTS ALLOCATED TO PROGRAM SERVICES (INCLUDED IN J):

$

K) GRANTS TO OTHER CHARITABLE ORGANIZATIONS

%

K) $

L) TOTAL CHARITABLE PROGRAM SERVICE EXPENDITURE (ADD J & K)

%

L) $

0

M) MANAGEMENT AND GENERAL EXPENSE

%

M) $

N) FUNDRAISING EXPENSE

%

N) $

O) TOTAL EXPENDITURES THIS PERIOD (ADD L, M, & N)

100 %

O) $

0

III. SUMMARY OF ALL PAID FUNDRAISER AND CONSULTANT ACTIVITIES:

(Attach Attorney General Report of Individual Fundraising Campaign- Form IFC. One for each PFR.)

PROFESSIONAL FUNDRAISERS:

P) TOTAL AMOUNT RAISED BY PAID PROFESSIONAL FUNDRAISERS

100 %

P) $

Q) TOTAL FUNDRAISERS FEES AND EXPENSES

%

Q) $

R) NET RECEIVED BY THE CHARITY (P MINUS Q=R)

%

R) $

0

PROFESSIONAL FUNDRAISING CONSULTANTS:

S) $

S) TOTAL AMOUNT PAID TO PROFESSIONAL FUNDRAISING CONSULTANTS

IV. COMPENSATION TO THE (3) HIGHEST PAID PERSONS DURING THE YEAR:

T) $

T) NAME, TITLE:

U) NAME, TITLE:

U) $

V) NAME, TITLE:

V) $

V. CHARITABLE PROGRAM DESCRIPTION:CHARITABLE PROGRAM (3 HIGHEST BY $ EXPENDED) CODE CATEGORIES

List on back side of instructions

CODE

W) DESCRIPTION:

W) #

X) DESCRIPTION:

X) #

Y) DESCRIPTION:

Y) #

IF THE ANSWER TO ANY OF THE FOLLOWING IS YES, ATTACH A DETAILED EXPLANATION:

YES NO

1. WAS THE ORGANIZATION THE SUBJECT OF ANY COURT ACTION, FINE, PENALTY OR JUDGMENT?

1.

MISAPPROPRIATION OF FUNDS OR ANY FELONY?

2

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.

PROPERTY OF ANY OTHER PERSON OR ORGANIZATION?

5.

6. DID THE ORGANIZATION USE THE SERVICES OF A PROFESSIONAL FUNDRAISER?

( ATTACH FORM IFC )

6.

7a. DID THE ORGANIZATION ALLOCATE THE COST OF ANY SOLICITATION, MAILING, ADVERTISEMENT OR

LITERATURE COSTS BETWEEN PROGRAM SERVICE AND FUNDRAISING EXPENSES?

7.

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?

8.

9. HAS THE ORGANIZATION EVER BEEN REFUSED REGISTRATION OR HAD ITS REGISTRATION OR TAX EXEMPTION

SUSPENDED OR REVOKED BY ANY GOVERNMENTAL AGENCY?

9.

10. WAS THERE OR DO YOU HAVE ANY KNOWLEDGE OF ANY KICKBACK, BRIBE, OR ANY THEFT, DEFALCATION,

MISAPPROPRIATION, COMMINGLING OR MISUSE OF ORGANIZATIONAL FUNDS?

10.

PREPARER (PRINT NAME)

SIGNATURE

DATE