SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
ADULT DAY HEALTH CARE OF MAD RIVER
 
Employer identification number

94-3005997
Identifier Return Reference Explanation
  FORM 990, PART VI, SECTION B, LINE 11 THE PROGRAM ADMINISTRATOR WILL REVIEW THE FORM 990 WITH THE BOARD OF DIRECTORS AND ANSWER ANY QUESTIONS PRIOR TO THE FILING OF THE TAX RETURN.
  FORM 990, PART VI, SECTION B, LINE 12C CONFILICT OF INTEREST MONITORING:THE BOARD OF DIRECTORS COMPLETE AN ANNUAL CONFLICT OF INTEREST DISCLOSURE DOCUMENT DETAILING ANY POTENTIAL CONFLICTS.
  FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC UPON REQUEST
CONTACT ADDRESSES FOR OFFICERS, DIRECTORS, ETC FORM 990, PART VII JEAN HAWKINS - 1542 J STREET, ARCATA, CA 95521. JIM PROCTOR - 1729 THUNDERBIRD, MCKINLEYVILLE, CA 95519. CAROLYN OILAR - 3556 DOWS PRAIRIE ROAD, MCKINLEYVILLE, CA 95519. ELEANOR SULLIVAN - 1645 ELBUTMO RANCH LANE, MCKINLEYVILLE, CA 95519. ESTER KILIAN - 4090 OLD RAILROAD GRADE, FIELDBROOK, CA 95519. DOTTIE HAUKENBERRY - 818 HUNTS ROAD, MCKINLEYVILLE, CA 95519.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

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