17053260008013-' Application. for Recognition of Exemption

Under Section 501 (c)(J) or the Internal Revenue Code

OMS Nc. 104H1056

NotB' If p.xempt st11tu., Is 'pproVOd. Ihis appilt:atton wit flO open fa publit; '"pccrlon.

Read lIle Instructions for each f'art carefully. A User Fee must be attached to this 3I-pDcat.lon.

If the required InforlOOl:on and appropriate documents am not submitted along with Form 8718 {with payment or the appropriate use1"l'ee}. the application may be returned to you.

Compkite the Procedural Checklist on page 8 or the InstructiollS.

Identification of Applicant

1a Full nama or organlzaUon (as shown In organizing dl)cument)

COUNCIL ON AMERICAN ISLAMIC RELATIONS

1b c/o Name (If applicable)

CAIA·SEATTLE

2 Employer identification number (EIN) (If none, see pege 3 or tile Specific lns!ructlons.)

68 10547353

3 Name and telephone number of per'\On to be contacted if additional information 15 needed

11: Address (number and street) I Room/Suite

12733 Lake City Way 302 ( 425 ) 443-5016 - Ahmad Hashem 1d City, town. or post office, Slate, and ZiP-"'-4"". i7f-yo-u""h-a-v-e-a-:f:-or-eJ.ig-n-a-d-:d-re-s-s.-f-47"';M~o-n""th:-:7th'e--a-n-nU-S":"I-ac-c-ou-n-tl;""ng-p-erO;-iOd-:-e-!I1d-=S­

see Specific Instructions (or Part I. page 3.

Seattle, WA 98125

1e Web site address I:ttp://www.cslr·seattle.crg

December 5 Date incorporated or formed

March 31 1 2003

6 Check hera if applYIng under section: a OS01ie\ bOSOlm c0501(k)dOS01(n)

7 Old the organilation previously apply for recognition of exemption under this Code section or under any other section of the Code? • • • • • . • • • • . • . . • 0 Ves :;j No If ·Yes," attach an explanation.

8 Is the organi7.atlO" required to me Form 990 (or Form 900·EZI? . . 0 N/A liZ! Ves 0 No If '~Jo: attach an explanation {see page 3 of the Sf!!!cific InstlUctions}.

!'I Has the orgunization filed Federal Income tax returns or exempt organization information returns? . . 0 Yes IZI No

If "Yes." state the form numbers. years filed. 3nd Internal Revenue ~OOTIX~~~~d. r~~t:;':"iV;:;[!

SEP 1 Z '03 SEP 16 '03

Check the box for the type of organization. AlTACH A CONFORMED COpy OF 1'HE;c6RRi:!s~O~lNG ORGANIZING DOCUMENTS TO THE APPLICATION BEFORE MAILING. (See SpecifiC Instructions for Part I. Line 10. on page 3.) See also PUb. 557 for examples of organizational documents.}

a 0 Corporation-Attach a copy of the Articles of Incorporation (including amendments and restatements) showing approval ":'y the appropriate state offici31; also include a copy of the bylaws.

b 0 Trust- At!DCh a .:opy of :M Trust Indenture or Agraemp.'ll. incltlcing all appropriate signatures aOL dates.

c 0 Association- Attach 3 cop}' of the Articles of Association. Const!!ution. or other creating document. with a declaration (see instructions) or other evidence the organization was formed by adoption of the document by more than 0OP. person; also Include a copy of the bylaws.

If the organization is a corporation or an unincorporated association that has not yet adopted bylaws. check here ~ 0 I declllm undar It!<! peMttiC5 or poIJury that I am authorlzoo ,0 sign this appHr.ation on b<lhall oIlhe abOve organization and that I hayo axamino<! this application.

ttl. ,""",mpanymg schOOulo. and attachments. and '0 .,.. 00.1 of my MOw/edge It is true. correct. end complete.

1-1-03 (Date)

Cat. No. 17133K

2

. 'Provide a detailed narrative d~scrlpllon ,of all the activities of the organization-past, present, and planned, Do not merely .. :.: ,: refer to or repellt the language In the organizational dCICUment, List each activity soparately in the order of ImpOflllnce , .. :. based On the relative lillie lind other resources devoted to the actiVity, Indicste the percentage of time fnt each actIVity.

Each description should Include. 8~ a minimum, 1hE; following; (a) a detailed description of the acU'/ity Including Its pL:poso , end how each ackivity (unhers your-exempt purp'ase; (b) "'{hen the activity was or will be inlliated; and (e) where and by wllOm the activity will be condUcted,

. Ple81G see attachment.

2 What are or will be the organization's sources of financial suppon? list in order of size. Donations (rom the public.

3 DeSCIibe the organization's fundraising program, both actual and planned. and explain to what extent it has been put into effecL Include details of fundl1lising activities such as selective maUings. formallon of funtlraising committees. use of volunteers or professional fundraisers. etc. Attach representative copies of solicitations for financial support.

The organization holds spnlllli fundrslslng events. Each event consIsts oi iI i"ndralslng banquet that targets 200 Individuals. The tvent consists of dinner follOWed by s drive to t,;,llc.;;t Gonatlons and pledges. So far, the organizatfllll held Q Ie slich event In May,2003. Tickets were sold for $351 person or $60 I couple. Attached Is a flyer u,&t the organization distributed throughout the Muslim ci)mmunlty to edvenlse for the fll'$t ftindrallling banquet. The .orgenlzatlon plans to IncreaSe the nllmber of such banquets hold to two or three !let year to cover Its expenses.

,""V'lJl'I,""U ... ON'AMERICAN ISLAMIC REtA TIONS t\1I,.~"I:",TTLE

Lake 'City Way,Suite 302 WA91U2S. .

.• :., E~: 68-0547353

- .'. . ~.. <.?<::: Attachment in lesponse to "Part II Question 1 .

.... ' .. , : .. Question: Provide a detailed narrative desl;.rirti~fI nr 1111 the activities of the organization-past, · present, and planned, Do not merely refer to 01' repeat the language in the organi7.ational

. doc,ument. List each activity separately in the .ordcr of importance based on the relative time and other resource~ devoted to the activity. Indicate the percentage oftiine for each activity.

Each description should include, as a minimum, the following: (a) II detailed desrription of the activity including its purpose and how. each activity furthers your exempt purpose; (b) when the activity was or will be initiated; and (c) where and by whom the activity will be conducted.

1) Activity: Public library book project

Percentage of time: 15%

Detailed description: Request donations from community members to sponsor delivery of selected and pre-screened books, videos and other educational material that provid~ a balanced

. View about Islam and Muslims. The goal is to sponsor up to 25% of the libraries in Washington · State by the elo,oi of this year,

Timing: Sbrted May 2003. On-going.

Where/by Whom: Conducted by the CAIR·Seattle education committee throughout the state of Washington. .

2) Activity: Educational publications andOrochures

Percentage of time: 15%

Detailed description: Distrirute/donate informational publications to various institutions and indio. ol~Jals that enlighten employers and officials pt:lspective about Islamic practices, PUbli...cltioils such as: Law enforcement guide to Islamic practices and Employer's guide to Islamic practices continue to be very popular resource that provide continuous resource for

. sensitivity and diversity training. · . .

· ,Tiliting: Planned

. ::',

.... .v .. n~ .... j!Jw,ON AMElUCANIStAMIC RELATIONS ,", ;'CAIR~SEATTLE' , , ";,12733Lake City Way, Stlite302

',Seattle,WA 98125 ' , ',ErN: 68-0547353

./ Where/by Whom: Conducted by th~CAIR-Senttle education committee throughout the state of , • Washington. - , ,

Coordinate educational workshops to enlighten Muslim Community on civil rights issues.

Percentage of time: 15%

, Detaileddmription: A:tivities would entail inviting speakers who specialize in areas of , human and civil rights to provide educational seminars. For example: Invited ACLU attorney to present a workshop on the civil rights with particular emphasis on and religious rights

, Timing: Started June 2003. Ongoing.

Wherelby Whom: Conduct.ed by the Ci'JR-Seattle education committee throughout the state of , " Washington.

4) ~ctivjty: Civil rights case work

Percentage of time: 15%

Detailed description: Help guide victims of discrimination (in the workplacl:. housing, etc), hate crimes, and civil rights violations to the appropriate recources and authorities based on the nef'ds of the individual case.

Timing: Started June 2003. Ongoing.

Where/by Whom: Conducted by the CAtR·Seat·tle civil rights committee throughout thG state of Washington.

5) Activity: Voter registration

Percentage of timp.: 15%

Detailed description: Promote voter registration to citizens in the Muslim community who are not registered to vote. Voter registration forms will be placed in places of worship, community

.. events, and Muslim-owned businesses.

'I.," :,",'.." " '- -.. ". .

'ON AMERICAN ISLAMIC RELA1'IONS TrLE '

, ,11P33 Lake City Way, Suite 302 ~Seattle;WA9g125 ' 'mN:>6S,,0547353

, , '

"Timing: Started May 20E.3. O!l-gomg.

:Whcrc!byWhoni: Conducted bv the CAIR·Seattle education committee throughout the state,of :'~:Washington. -

,6) Activity: Community media monitoring and action alelts

, l'ercentllgc of time: 10%

, Detailed description: Members of the CAlR-Seattte Media Committee currently are monitoring 'print, radio ~nd television media outlets for new stories and publications relevant to American

Muslims, Stories that have both a positive and negative impact on Muslims are noted and shaied 'with other, members of the Media Committee and with a larger emnillist of general CAlR , members in the greater Seattle area. Through action alerts, members are then encouraged to 'contact the appropriate media outlets to voice their approval or concern, .

. Timing: Started May 2003. On-going,

. Where/by Whom: Conducted by the CAIR-Seattle media committee throughout the state of Washington.

7) Activity: Media appearances and news conference preparation

Percentage of time: 5%

. Detailed description: As newsworthy issues of importance to the Seattle-area Muslim community arise, CArR-Seattle will respond to requests from media outlets for infomJation and when needed, will call press conferences in order to present the Muslim perspective. Interviews with media outlets will primarily be given by a designated CAIR~Seattle spokesperson. f,dditionally, other qualified individuals associated with CAIR-Seattle, such as board members or community leaders, may represent CAIR·Seattle. The location for such interactions varies according to the circumstances surrounding each event but may include the CArR·Seattle office, board members homes, or locations where the news event is taking place,

Timing: Started May 2003. On-going.

'''herelby Whom: Conducted by the CAIR·Seattle media committee throughout the state of : Washington.

.'~ . 8} ....

'.Activityi Voter ettucatlon ' ' .... : :' .... '. Percentage otlime: 5% .'

'\.,

..... :",

. Detailtd deseription:Promoie understanding of basic civics and the United States political . ,sysiem.Topics to include thetbree.branch~ystem of government and election procedures across

local, sfate, andfederal government. .... ". ..... ':,

Thiiing: Planned fC1'2004. . . ,

Wherelby Whom: Condu~ted by the CAIR·Seattle education committee throughout th~ state of Washington .

. ~f. . 'Activity: Public School Outreach

' •. 'Percentage of time: S% . . .'

:' ." Detailed description: Serve as !flJest speakers in public schools on topics relating to Islam and :: Muslims. Serve as reviewers of school curricula for correct depiction of historical, cultural and :,: teligious content on Islam and make recommendations for improvements andlor removal of

erroneoilscontent.

Timing: Planned for 2004.

Wherelby Whom: Conducted by the CAIR·Seattle education cornmit!ee throughout the state of . '. Washington.

b Annual compensation

Plels. eel attachment. ...

'. '.:c 00 any of the above persons serve as members 01 til€: governing body by reason of being publi.:: officials .. , or being appointed by public otnclals? ,., • • • • • • • , • • , , • , • , • , , • 0 Yes i2I No

1('Yes," namo Ihose persons and explAin thll basis of their selection or appointment.

. :. '.: d Are any members of the organlzatlon's governing body "disqualified persons" with respect to Ihe organizalion (othllr than by reason 01 being a member of the governing body) or do any (\f the members have either II business or family relationship with "disqualified persons"? (See SpecifiC: InstrUctions for

. ParI II. Une 4<1. on page 3.) • , , , , • • , • , , • • • , , , • • • • , • • • • 0 Yes i2I No II ·Yes." explain.

Does the orqanization control or is il controlled by any other organization? • • • , , . • , • , 0 Ves i2l No Is the organization thA outgrowth of (or succe:;sor to) another organization, or does it ha'is a special relationship with another organization by reeson of Interlocking dlnectorates or other facters? • 0 Ves I2J No ~I either of these questions is answered ·Yes." explain.

Does or will the organization riirecUy or Indirectly engage in any of the following transactions wkh any pOlitical organization or othar exempt organization (other than a 501 (cl(31 organlzallonl: (a) grants:

. (b) purchases or sales of assels; (c) renlal of facilities or equipment; (d) loans or loan guaranteAs; (e) neimbursement arrangements: (I) performance or services. membership. or fundralslng solicitations; or (g) sharing of facilities. equipmenl. mailing lists or other assets. or paid employees? • , • • • • 0 Ves 0 No If 'Yes,' explain fully and identify the other organizations involved •

. . Organlzaglon plans to share mailing lists and consult with a Washington, DC organization called the Council on ;. .. i ... i.. .. ,,·j .. iltlllie Relations, 453 Now Jersey Ave SE, Washington, DC 20003-4034. Tel 202.488.8787,

.Is the organization financially accCluntable to any other organization? • , , • , • , , • , • , D Ves I2J No If. ·'/e;;." explain 'lnd identify the other organization. Include details concerning accountablnty or attach

. . ~pies Of reports If any have been suonittteil.· .

, . ,:' :A~~chtneni in response to .Part II QueStion 4 a and b

.. , utll Gn: Ive leo owma In ormatIon a ut t e orgamzatlon s governmg 0 Iy --) .;, Nliiiii:i;jnildnsses, andtitlcs or officers, directors, trustees, etc b.AnDluil bo h •• I . b d

compensation ._ Ibrahim Oebol Mohamlld, 101.1715t Place SE, Bothell, WA 98012, 0 .• ~a~~. __ ~ '.' '.' . __ . . --'SaminEI-Moslimanl::i P.O. Bolt367, Seahurst,WA98062. Vice-Chairman' 0 --. Abdulkadir Adam Jama,15403 SENewportWay, Bellewe, WA 98006, o '. 'Treasurer

.'.' Ahmad Hashem,43061S6th Avenue NE, BRIOS, Redmond, WA 98052, 0 Secretary Rami AI-Kabra, 13520 Linden-Avenue N #522, Seattle. WA 98133, Board 0 'Member·

.... Syed }UzwllnNasr, 8541 Avondale Ro.ad NE, Redmond, WA 98052, Board 0 Member

:-: ·!inranRafiQ • .l7108 SE 29 CT, Bellevue.WA 98008, Board Member a Ribhi Shawar,14732 SE 66th St., Bellevue, WA 98006, Board Member 0 Naseem Tutraha, 5714 34th Avenue NE,Seattle. WA 98105, Board Member 0

4

(In.~rt\!'Jnn .. 1 Information (Contlnuod)

. does the organizotlon have that are USIlIJ In the p~rforrr.dnca of its m.ampt function? (Do nOllnclude property ;d~II:Clti'lcirl/1 In've.ltma:nt incomn.) if allY assets .are not fully operatlonn '3xploln their staluS, what additional stops remain to

cbinnJelelj. and when such finEli stops wUltJe laken. If nona, indicate "NlA."

.... organization be lha beneficiary of t8X·l'Ixeinpt bond financing within the next 2 years7.

Will any or the organization's facilities or operations be managed by another organizallon or Individual tinder a contractual agreement? . • •... .:. . .'. • • • . • . • • . • • • • • Isthe organlratlem a party to any ledslls? • • • • • • • . • • • . • • . • . • • • • Ifalther 01 thesn questions is answered "Yes: Bttach a copy or the contracts and explain the relationship

.. between U'B applicant and tha other partlefi.

is the organization a membership organization? If ·Yes." complme the following:

a Dascribe the organizatlon's membership requirements and attach a schedule or membarshlp fees and dues.

Describe the or9ilni~aUon's present and proposed affons to attra<:t members and auach a copy of any descriptive literature or promotional materiul used for this purpose.

'c What benr:fits do (or will) the members receive In eXChange for their payment of dues?

DYes 0 No

DYes 21 No DYes 0 No

If thE: organillltion provides benefits. services, or products. are the recipients required. or will they be required. to pay for them? • • • • • • • • • • • • . . • • • . • . 0 NJA 0 Yes i?i No If "Ye:.." explain how the charges are determined and anaen a copy of the current fee schedule.

b Does or will the organization limit its benefits. ~"ice~. or . products to specific Individuals or . classes of individuals? • • . . • • • . • . • • . • • • • . • • '. . • • 0 NIA 0 Yes 0 No If "Yes," explain haw the recipients or benefiCiaries are or will be selected.

Does or will the organization attempt to influence legislation? • . . . • . . • . . . . • . 0 Yes 0 No Ir -Yes." explain. Also. give an estimate of the percerltage of the organization's time and funds that it devotes or plans to devote to this activity.

)JoesorwiU the organization Intervene In allY way.in political campaigns. including the publication or distrlbutionof statemems? . . • • • . . • • • . . • • • . • .' • • • . • • • 0 Yes 0 No I( "Yes: explain fully.

filing Fonn 1023~:thlrI15 months frcmthoend of tha month In wh;ch your organization was at lomied? • .• .' •• '. •. ..'.:'.... •• . • • . . • • • • ' . • i?J Ves 0 No

·Yes," do not ansWer quaSII"lnS ~ lin~s 2 ttlrough 6 below ..

exceptions to It,e' 15·momh filing requirement shown billow applies. check the approprlBte box and proceed ."',"".,,.1,," 1. ,~:KcepUDn5;-'~ou am not.requlred to file an exemption application within 15 months If the organi7.aUon:

. lsa church. Interchurch organization of IDcaiunits of a' church, a convention or association of churches. or an Integrated auxiliary of a church. See SpeCifiC Instructions, Llno 2a, on paga 4: ls,not a private foundation and normally has grossrece,ipts of not more than 55.000 in eaclt tax year: or

exemption lotter. but only If the parent or supervisory organization

Ifihe organization dop.s not meet any of the exceptions on line 2 above. are you filing Form 1023 within : ·27 months from the and of tile month In which the organlz.ltion was creotr.d or formed?, , . • . • 0 Ves 0 No

If"Vas: your organization qualifies under Regulation section 301,9100·2. for an automatlc 12·rnonlh · i)'Iteniifon of tile 15,month flllng requirement. Do not answer questions 4 tl1nough 6,

'. 'No. k answer question 4 •

. , . ,If you answer "No' to question 3. does the organization wish to request an extension of time to apply under the "reasonable action and good faith" and lhe "no prejllrlicA to the Interest of the government" ,r~;rements of Regulations section 301.9100·31. • • • • • • . , • . . , . , . • , • 0 Ves 0 No

If "Ye5 ... give the rea~ons far not filing this application within the 27 ·month perioe! described In question :;, See SpeCific Instructions,Part III. Line 4. before completing this item. Do not answer questions 5 and 6.

If "No." answer questions 5 and 6.

· If you- allswer "No" 10 question 4. your 'organization's qualification as a section 501(c)(3) organization can be recognized cnly from the date this application is filed. Thorefore. do you want IJS to consider the application as a request for recognition of exemp1iQn as a section 501(cK3) organization from the date the application Is received and not retroactively to the date the organization was created or flll'med? • 0 Yes 0 No

. If you answer "Yes" to qUijstion 5 above and wish to reque~,t :",,;ognition of seclion 501(c)(4) status fo; the period beginning With the date the organization was formed and ending with '.:~d date the Form 1023 application was received (the effective

· date of lhe organization'S section 501 (c)(3\ status). cheCk hAre" 0 and attach a completed page 1 of Form 1024 to this · application,

, ':islheorganlzlltlon a priVatI! foundaito~? ", ,n 'Yes (Answer question 8.) ,

, ":"; 0, No (llnswerquestlon 9 and proceed eS./L'slrUcted.)

, If you answer "Yes" to question 7. does tile organization claim to be a privata operating foundation? , 0 ,VftS (Complete SchRdule E,) , o No

,After answering question B on this line. go to line 14 on page 7.

If you answer "No· to question 7. indicate the public chllr;ty classification the orgar.lzatlon Is requesting by checking the box below that most appropriately appHos:

THE ORGANIZI<TION IS NOT A PRIVATE FOUNDATION BECAUSE IT QUALIFIES:

a 0 As a church or a con\'I!Iltion or association of churches Sections 509(e)(1) (CHURCfIES MUST COMPLETE SOIEDUI.E A.) and 170(b)i1 )(Alm

Secllons 509(a)(1) 0 A.~ a school (MUST COMPLETE SCHEDULE B,) and 170(b)(1 )(A)P6

c 0 As 8 hospitnl or 8 cooperative hospital sarvice organization. or a medical research organization operated In colliunctlon with a Sections 509(a)(1) hospital (Th'l5e organizations. po:cepl for hospital se:vice and 170(b)(1)(A)(ilQ organizations. MUST COMPLETE SCHEDULE C,)

b Sections 509(8)(1)

d As a governmental unit described In section 17O(c)(1). and 17O(b)(1)(A)(v)

e 0 As being operated solely for tile benefit of. or In connection with. ona or more of the organizations described In a through d. g. h. or I (MUST COMPLETE SCliEDULE D.) Section 509(a)(3)

0 As being org,1nized and operated exclusively for testing for public safety. Section 509(a)(4)

g 0 As being operated for the ilsnefit of a cc'"ege or university that Is Sections 509(a)(1) owned or operated by a governmental unit. and 170(b)(1)(A)(iv)

h Ii!! As receiving a substantial part of il'i suppAft in the form of contributions from publicly supported organizations. from a Sections 509(a)(1) governmental unir., or from the general public. snd 170(b)(1)(A)(vQ

I 0 As normally receiving not more thlln one· third of its support from gross investment Income and mol'l! than one-third of its support from contributions. membership fees, and gross receipts from actlviUes related to ilS exempt functions (SUbject to certain excoptlons), Section 509(a)(2)

j 0 Tha organization is a pllalicly supported organization but Is not sure Sections 509(a)(1) ..... hether it meets tile public support test of h or I. The organization and 170(b)(1)(A)(vi) would like the IRS to decide the classification. or Section

If you checke,d one of the boxes a through f In question 9. go to question 14. If you checked box g In question 9. go to quostlon~ 11 and 12_

If r-:.I checked box h. i. or j. in question 9, go to question 10. '" "

6

If you checked . box h. i. or j In' question 9, has the organlz~tlon completed a lax Yflar of at least B months? o VaS-IndICate whether you ijr!! requesting:

. OA dennltive rullng.!Answef questlonsn :hrouyh 14.) O· An advance ruling. (Answer queStions 1 rand i4 and attach two Forms B72-C completed and signed.)

1

·0 Nc,..;..vou must request 6n advance AIling by. completing and Signing two Forms 872·C and attaching tllom to the . Form 1023. .'. -.- ....... . -

If theorg<lnl1.atlcn received any unu"uBI grants during any of the tax years shown in Part IV-A. Statement of Revenue and Expenses, atlach D list for each year s'1owlng 111e n3mo of the contrltiulor; the date and the amount of the grant; and a brief d!lscrlptlon or the nature or the grant. .

---- - •. If YOll are roqunsting a del1nitlve rutlng under seelion 170(b)(1)(A)(lv) or (vi). check here ~ 0 cnd:

. a Enter 2% of line 8. column (e). TOlal. o( Part IV-A . . _ • . • • _ . • • • . . . b Attach 8 list shOwing the name and amount contributed by BACh person (other than a governmental unit or "publicly . suppOfted" organizatio'l) whose total gifts. grants. contributions. etc .. were more than the amount entered on line 128 .' above,

.... ~~----------------------~--------------~----------------------. 13 If youare requesting a definitive ruling under section 509(a)(2). check here ~ 0 and: . a For each Of the years Included on lines 1. 2. and 9 of ParIIV·A. attach a list showing the name of and amount received

. (rom each "disqualined person." (For a definition of "disqualified person," see Specific Instructions, Part II. Une 4d. on . ' .. page 3.) . b For each of tho years included on line 9 'Jf Part IV-A. attach a list showing the name of and amount received from each

than a'dh:;qualined person"l whose payments to the organization were more than $5.000. For this purpose. but is not limited to, any organization described In sections 170(b)(1)(A)(O through (v!) and any

Indicate if your organization is ona of the (ollowing. If so. complete the required schedule. (Submit only those schedules that apply to your Ofganization. Do not submit blank schedules.)

Is the organization a church? • • . . •

Is the Ofganlzation,. or any part of It. a school?

15 the organizntiorl. or any part of it. a j·.uspital 0lJ!1edical re.search organization?

Is the organization a section 509(a)(3) supporting organization?

Is the Ofganization a private operatlng foundation? _ . . .

15 the organization. or any part Qf it. a home for the <':;Jed or hamlicapped7

Is the organizatfon, or any part of it, a child care organization? , . , .

Does the orgalliZlllion provide or administer any scholarship benefits. student aid. etc.?

Yes If ",'cs,"

No C'.omplete Schedule~

V

V

V

>./

V

¥ F

¥

V

V

flllallcllll st81ement~ for the current year IJnd for each of rna 3 years imrnedl~7tely beforo It. If In exlstencp. less cornp~eCf1 the st8tement.~ (or each year in exlsl'ence. If In cxlstcmco loss than 1 YOllr, alsl) provldo proposed

tho 2 thc

Gilts, gmnts, and contribuTions received (not Including llnusual gral1ts-soo page 6 of tho Instructions). . . Membership fees received •

Gro~ls .InvcstmCl1t Income (sec in:;tructions for dcflnioon)

Net incomo lrom organization's urue!atcd bu~lnflss activities not Incl'Jdcd on line 3 •

'1 tiX revcnuus levied lor and citrn:r paid to or spent on behalf

· of Ule organization 6 Value 0/ ~;crviccs or f~cilitics

furnlsl1Cd by a governmental unit to too Jrganizatlon without clvlrgc (not indudlng !ho value of services or faciWcs generally furnished the public wilhout charge) .

Other illcolno (root including gain or los~ Irom sale or capital assets) (attaCh schedule) Total (add lines 1 through 7)

Gloss rcc(~pts from admissions, sales of mCfchand;sc or sr.rvices, or furnislling of facilities in any activity that is not an unrelated business within the meaning of section 513. Include related cost of ~alC$ on line 22 • Total (add lines !! and 9)

Gain or loss from sate of capital assets (attach schedule). Unusual grants. Total revenue (add lines 10

ContributiorY." gifts, gmnts, and similar amounts paid {attach schedulc:} Disbursements to or for benefit of mell~bers (9tt~ch ~chedule) •

Compensation of officers, directors, and trustees (Jttach

: schedule) · Other salaries. Jnd wages

Interest • · Occupancy (tent, utilities, etc.).

Depreciation and depiction. • Other (attach o;chedute): . . TO~lexpcnses (add lines 14

· throu~h. 22) .. · F xr~-ss·. 01

(e) TOTAL

o o o

o o o

o o o

o

o

. . .. .. . ...... ;.:.'.

~;:~:J\.lt~chnlent in 'supj>ort of Part IVLlrie 22·' . ........ :

··.·::.·ThemiscellanIJoulS expense s~hedule·

Yrs 2003 2004· 2005 ·Descril)tlon . Amount Amount Amount

··Postage; 40 250 . 350 Monthly events. 316 350 450

: PrinUng· ·368· 650 850 others 0 250 350

.·I·roI81 724 1500 2000

. :.',

.... , .....

,1 t,

, .

.. . :·;,eoricis and nO{es receivabla (attach schedulo) •

. <Caporate stocks (attllch schedule).

. . MClI1l;'1ge 103ns (aU8ch schedule) •

Other Inveslme-fIIs (attach schedule)

. '

: .:. Depr8l!lable and depletable asseu. (atlach schecJule) •

'.

.. O~her assets (atlach schedule)

Total assets (add lines 1 through 10) •

Uabllitles . Accounts payable

Comtlbutions. gills. grants. etc., payable.

Mortgages and notes payable (attach schedule)

.. Other Dabilities (attach sChedlil~) • • • • •

Total 6abilities (add Unas 12 through lil- .

..

' .

.. Fund Balances or Net Assets

. Total fund balances or net essets

0

u

0

C

0

0

0 . ..

0

0

880

o

o

o

880

20,619

21.499

financial activities since the end of the period ...............• 0