SCHEDULE O
(Form 990)

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 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
Name of the organization
ADIRONDACK SAMARITAN LICENSED
CLINICAL SOCIAL WORK PC
Employer identification number

26-4642350
Return Reference Explanation
FORM 990, PAGE 6, PART VI, LINE 11B FINANCE COMMITTEE REVIEWS 990 AND APPROVES IT.
FORM 990, PAGE 6, PART VI, LINE 12C EXECUTIVE COMMITTEE REVIEWS CONFLICTS OF INTEREST STATEMENTS SIGNED BY BOARD MEMBERS ON AN ANNUAL BASIS.
FORM 990, PAGE 6, PART VI, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE FURNISHED UPON REQUEST.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990) 2021


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