b
If "Yes," list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.
(i) Name and address of individual
or entity (fundraiser)
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(ii) Activity
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(iii) Did fundraiser have custody or control of contributions?
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(iv) Gross receipts
from activity
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(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i)
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(vi) Amount paid to
(or retained by)
organization
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Yes
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No
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Total .
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3
List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from registration or licensing.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2016
Schedule G (Form 990 or 990-EZ) 2016
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" on Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.
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(a) Event #1
(event type)
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(b) Event #2
Others
(event type)
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(c) Other events
(total number)
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(d) Total events
(add col. (a) through col. (c))
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1
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Gross receipts
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2
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Less: Contributions
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| 3 |
Gross income (line 1 minus
line 2)
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| 4 |
Cash prizes
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| 5 |
Noncash prizes
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| 6 |
Rent/facility costs
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| 7 |
Food and beverages
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| 8 |
Entertainment
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| 9 |
Other direct expenses
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| 10 |
Direct expense summary. Add lines 4 through 9 in column (d) .
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| 11 |
Net income summary. Subtract line 10 from line 3, column (d).
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Part III
Gaming.
Complete if the organization answered "Yes" on Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
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(a) Bingo
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(b) Pull tabs/Instant
bingo/progressive bingo
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(c) Other gaming
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(d) Total gaming (add col.(a) through col.(c))
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1
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Gross revenue
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2
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Cash prizes
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3
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Noncash prizes
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4
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Rent/facility costs
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5
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Other direct expenses
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6
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Volunteer labor
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7
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Direct expense summary. Add lines 2 through 5 in column (d) .
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8
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Net gaming income summary. Subtract line 7 from line 1, column (d).
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9
Enter the state(s) in which the organization conducts gaming activities:
a
Is the organization licensed to conduct gaming activities in each of these states?
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10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year?
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Schedule G (Form 990 or 990-EZ) 2016
Page 3
11
Does the organization conduct gaming activities with nonmembers?
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13
Indicate the percentage of gaming activity conducted in:
a
The organization's facility
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13a
%
b
An outside facility
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13b
%
14
Enter the name and address of the person who prepares the organization's gaming/special events books and records:
Name
Address
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue?
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b
If "Yes," enter the amount of gaming revenue received by the organization
$
and the
amount of gaming revenue retained by the third party
$
.
c
If "Yes," enter name and address of the third party:
Name
Address
16
Gaming manager information:
Name
Gaming manager compensation $
Description of services provided
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license?
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b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year
$
Part IV
Supplemental Information. Provide the explanations required by Part I, line 2b,
columns (iii) and (v); and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also
provide any additional information (see instructions).
| Return Reference |
Explanation |