SCANNED AUG 2 5 2013 I Form Department of the Trsury lntemal Revenue Service EXTENSION GRANTED TO AUGUST 15. 2011 Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(a)(1) of the lntemal Revenue Code (except black lung bene?t trust or private foundation) The organization may have to use a copy of this retum to satisfy state reporting requnements. OMB NO 1545-0047 2009 Open to Public inspection A For the 2009 calendar year, or tax year beginning OCT 1 2 0 0 9 and ending SEP 3 0 2 0 0 3:57;ng Please Name of organization Employer identi?cation number use States 132:: 3: ITI ZENS FOR A WORKING AMERICA, INC . 24:39:36 type Domg Busmess 13113531 See Number and street (or P.0. box if mall IS not delivered to street address) Room/sum: Telephone number ggnm- 131 NORTH LUDLOW STREET 315 804?462?3429 :?oTuenqded "ms City or town, state or country, and ZIP 4 Gross receipts 333m' AYTON . 0H 4 5 4 2 H(a) Is this a group return pending Name and address of QUINN for af?liates? Yes No SAME AS ABOVE H(b) Are all affiltates Included? : Yes El No I Tax-exempt status: LXJ 501 4 Website: A Form oforgamzalion: Corporation LJ Trust Assomation Otherh )4 (insert no.) 4947(a)(1) or LJ 527 Part I Summary If attach a list (see instructions) H(c) Group exemption number I Year of formation: 2 0 0 9] State at legal domICile: DE ni Signature Block 0 1 Briefly describe the organization's missmn or most Significant activrties- TO PROMOTE SOUND ECONOMI POLICY: 1 BY ENGAGING IN INITIATIVE AND 2 Check this box if the organization discontinued operations or disposed of more than 25% of its net assets. 3 3 Number of voting members of the governing body (Part VI, line 1a) 3 3 4 Number of independent voting members of the governing body (Part VI, line 1 b) 4 3 3 5 Total number of employees (Part V, line 2a) 5 0 6 Total number of volunteers (estimate if necessary) 6 3 7a Total gross unrelated business revenue from Part column (C), line 12 7a 0 Net unrelated busmess taxable income from Form 990-T, line 34 7b 0 - Prior Year Current Year q, 8 Contnbutions and grants (Part line 1hProgram semce revenue (Part vm, line 29) 10 investment Income (Part column (A), lines 3, 4, and 7d) 1 1 Other revenue (Part column (A), lines 5, 6d, 8c, 90, 100, and He) 12 Total revenue - add lines 8 through 11 (must equal Part column (A), line 12Grants and Similar amounts paid (Part IX, column (A), lines 1-3) 14 Bene?ts paid to or for members (Part lX, column (A), line 4) 15 Salanes, other com E1 (Part column (A), lines 510) 16a Professmnal fundrai ingf (1) e) Total fundraismg ex 5 (Part IX, column (D), ?meta 17 Other expenses (P olu @g-Wd, 1?th2 Total expenses. Add l?'E 13-17 (must equal Part IX, (A), line 25Revenue less expen Beginning of Current Year End of Year 20 Total assets (Part X, line Total Ilabtlities (Part x, line 26) 3 Net assets or fund balances. Subtract line 21 from line Under penalties of perjury, ldeclare I have examined this return, tncludtng accompanying smedules and statemnts, and to the best of my knowledge and belie?i, it is true, conect, and complete iaration 01 prepar er than of?cer) based on all information of which preparer has any knowledge Sign I Here /3ignlature of Met Date NORM CUMMINGS . URER Type or name and title Paid Preparers D. 111 Date ggeek it number Preparers Signature 0 8 1 2 1 employed El Use Only VJ.D . CLOUD coFOURTH STREET SUITE 1 1 0 CINCINNATI, OHIO 45202-4007 Phoneno. >(513) 621-1188 May the IRS discuss this return With the preparer shown above? (see instructions) Yes LR 932001 02-04-10 LHA For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Form 990 (2009) SEE SCHEDULE 0 FOR ORGANIZATION MISSION STATEMENT CONTINUATION Form 990 (2009) 27?0585219 CITIZENS FOR A WORKING AMERICA, INC. Page2 Wart Statement of Program Service Accomplishments 1 Briefly descnbe the organization's massron: TO PROMOTE SOUND ECONOMIC POLICY: 1) BY ENGAGING IN INITIATIVE AND EFFORTS, 2) BY PARTICIPATING IN THE PUBLIC POLICY ARENA, AND 35 BY PROVIDING EDUCATIONAL SERVICES TO THE GENERAL PUBLIC . 2 Old the organization undertake any program servrces during the year which were not listed on the pnor Form 990 or 990-EZ9 (:lYes No If "Yes," describe these new servrces on Schedule 0 3 Did the organization cease conducting, or make Significant changes In how It conducts, any program servrces?? ?: Yes No if "Yes," describe these changes on Schedule 0 4 Describe the exempt purpose achievements for each of the organization?s three largest program sen/Ices by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) are requrred to report the amount of grants and allocations to others, the total expenses, and revenue, If any, for each program servrce reported 43 (Code' (Expenses Including grants of )(Revenue THE ORGAN I ZATION ENGAGED IN BALLOT ISSUE ADVOCACY ON ECONOMIC ISSUES . 4b (Code: (Expenses Including grants of (Revenue 4c (Code (Expenses including grants of )(Revenue 4d Other program services. (Descnbe to Schedule 0.) (Expenses 35 Including grants of (Revenue 4e Total program service expenses>$ 2 257 024 . Form 990 (2009) 932002 02?04-10 ,Form see (2009) CITIZENS FOR A WORKING AMERICA, INC . 27?0585219 Page3 [Part IV Checklist of Required Schedules Yes No 1 Is the organization described In section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes, complete Schedule A 1 2 is the organization reqwred to complete Schedule B, Schedule of Contributors? 2 3 Did the organization engage in direct or indirect political campaign activities on behalf of or in opposmon to candidates for public of?ce?? If "Yes," complete Schedule C, Partl 3 4 Section 501(c)(3) organizations. Did the organization engage in lobbying actIVities? lf "Yes, complete Schedule C, Part ll 4 5 Section 501(c)(4), 501(c)(5), and 501(c)(6) organizations. Is the organization subject to the section 6033(e) notice and reporting requwement and proxy tax? If "Yes, complete Schedule C, Part 5 6 Did the organization maintain any donor adwsed funds or any similar funds or accounts where donors have the right to provrde adwce on the distribution or investment of amounts in such funds or accounts? If "Yes, complete Schedule D, Part I 6 7 Did the organization receive or hold a conservation easement, Including easements to preserve open space, the enVIron merit, historic land areas, or historic structures? If ?Yes, complete Schedule D, Part ll 7 8 Did the organization maintain collections of works of art, historical treasures, or other Similar assets? If ?Yes, complete Schedule D, Part 8 9 Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part or provide credit counseling, debt management, credit repair, or debt negotiation sewices? If "Yes, complete Schedule D, Part lv 9 10 Did the organization, directly or through a related organization, hold assets in term, permanent, or quad-endowments" If "Yes," complete Schedule D, Part 10 11 Is the organization's answer to any of the followmg questions ?Yes?? If so, complete Schedule D, Parts Vl, Vll, IX, or as applicable 11 0 Did the organization report an amount for land, buildings, and equrpment in Part X, line 10? If "Yes," complete Schedule D, Part 0 Did the organization report an amount for investments - other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 169 If "Yes, complete Schedule D, Part VII 0 Did the organization report an amount for investments - program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes, complete Schedule D, Part WI 0 Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If ?Yes, complete Schedule D, Part IX. 0 Did the organization report an amount for other liabilities in Part X, line 25'? If "Yes," complete Schedule D, Part X. 0 Did the organization's separate or consolidated ?nanCIal statements for the tax year include a footnote that addresses the organization?s liability for uncertain tax posrtions under FIN 48? If "Yes, complete Schedule D, Part X. 12 Did the organization obtain separate, independent audited fmancral statements for the tax year? If ?Yes, complete Schedule D, Parts Xl, Xll, and 12 12A Was the organization included in consolidated, independent audited ?nanCial statements for the tax year?? Yes No If "Yes, completing Schedule 0, Parts Xl, Xll, and IS optional 12A 13 Is the organization a school described in section 1 If ?Yes, complete Schedule 13 14a Did the organization maintain an of?ce, employees, or agents outside of the United States? 14a Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraismg, busmess, and program semice outSIde the United States? If ?Yes, complete Schedule F, Part I 14b 15 Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or to any organization or entity located outSIde the United States? If "Yes," complete Schedule F, Part II 15 16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or a55istance to indiwduals located outsrde the United States? If ?Yes, complete Schedule F, Part 16 17 Did the organization report a total of more than $15,000 of expenses for professronal fundraismg servnces on Part IX, column (A), lines 6 and 119? If ?Yes, complete Schedule G, Part I 17 18 Did the organization report more than $15,000 total of fundraismg event gross income and contributions on Part lines 1c and 8a? If "Yes," complete Schedule G, Part ll 13 19 Did the organization report more than $1 5,000 of gross income from gaming activmes on Part Vill, line 93? If "Yes," complete Schedule G, Part Ill 19 20 Did the organization operate one or more hospitals? ll ?Yes, complete Schedule 20 Form 990 (2009) 932003 02-04-10 .Form geolzooe) CITIZENS FOR A WORKING AMERICA, INC. 27?0585219 Page4 rPart IV Checklist of Required Schedules (contlnued) Yes No 21 Did the organization report more than $5,000 of grants and other assmtance to governments and organizations In the United States on Part IX, column (A), line 1? If "Yes," complete Schedule I, Parts land It 21 22 Did the organization report more than $5,000 of grants and other to individuals in the United States on Part IX, column (A), line 2? If "Yes, complete Schedule I, Parts land Ill 22 23 Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization?s current and former officers, directors, trustees, key employees, and hrghest compensated employees? If "Yes, complete Schedule 23 243 Did the organization have a taxexempt bond issue an outstanding amount of more than $100,000 as of the last day of the year, that was Issued after December 31 2002? If "Yes, answer lines 24b through 24d and complete Schedule K. If go to ?ne 25 24a Did the organization Invest any proceeds of tax-exempt bonds beyond a temporary period exception? 24b Did the organization maintain an escrow account other than a refunding escrow at any time dunng the year to defease any tax-exempt bonds? 24c (I Did the organization act as an "on behalf of? issuer for bonds outstanding at any time during the year? 24d 253 Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefrt transaction With a disquali?ed person during the year? If "Yes," complete Schedule L, Part I 25a Is the organization aware that it engaged in an excess benefit transaction With a disquali?ed person in a year, and that the transaction has not been reported on any of the organization's pnor Forms 990 or If ?Yes, complete Schedule L, Part I 25b 26 Was a loan to or by a current or former of?cer, director, trustee, key employee, highly compensated employee, or disquali?ed person outstanding as of the end of the organization?s tax year? If "Yes," complete Schedule L, Part ll 26 27 Did the organization prowde a grant or other asmstance to an of?cer, director, trustee, key employee, substantial contributor, or a grant Selection committee member, or to a person related to such an individual? If "Yes, Complete Schedule L, Part 27 28 Was the organization a party to a busmess transaction With one of the followmg parties, (see Schedule L, Part IV instructions for applicable ?ling thresholds, conditions, and exceptions): a A current or former of?cer, director, trustee, or key employee? If ?Yes, complete Schedule L, Part IV 28a A family member of a current or former of?cer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV 28b An entity of which a current or former officer, director, thstee, or key employee of the organization (or a family member) was an of?cer, director, trustee, or direct or indirect owner? If "Yes, complete Schedule L, Part lv 28:: 29 Did the organization receive more than $25,000 ln non-cash contnbutions? lf "Yes, complete Schedule 29 30 Did the organization receive contributions of art, histoncal treasures, or other Similar assets, or qualified conservation contributions? If "Yes," complete Schedule 30 31 Did the organization liqUidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I 31 32 Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets?? "Yes," complete Schedule N, Part ll 32 33 Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301 .7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part! 33 34 Was the organization related to any taxexempt or taxable If "Yes," complete Schedule Fl, Parts ll, Illany related organization a controlled entity wrthin the meaning of section 512(b)(13)? If "Yes," complete Schedule Fl, Part V, line 2 35 36 Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-chantable related organization? If "Yes. camplete Schedule H, Part V, llne 2 36 37 Did the organization conduct more than 5% of its activities through an that is not a related organization and that rs treated as a partnership for federal income tax purposes? lf ?Yes, complete Schedule Fl, Part 37 38 Did the organization complete Schedule 0 and provrde explanations in Schedule 0 for Part VI, lines 11 and 19? Note. All Form 990 filers are requwed to complete Schedule 0. 38 Form 990 (2009) 932004 02-04- 10 . Form 980 (2009) CITIZENS FORA WORKING AMERICA, INC . 27?058 5219 Page5 [Part Statements Regarding Other IRS Filings and Tax Compliance Yes No 1a Enter the number reported rn Box 3 ol Form 1096, Annual Summary and Transmittal of U.S Information Returns Enter -0- if not applicable 1a 0 Enter the number of Forms included In line 1a. Enter if not applicable 1b 0 Did the organization comply backup Withholding rules for reportable payments to vendors and reportable gaming (gambling) Winnings to prize Winners? 16 23 Enter the number of employees reported on Form W-3, of Wage and Tax Statements, filed for the calendar year ending With or the year covered by this return 23 0 If at least one IS reported on line 2a, did the organization file all requrred federal employment tax returns? 2b Note. If the sum of lines 1a and 2a is greater than 250, you may be requrred to e-?le this return. (see Instructions) 3a Did the organization have unrelated busmess gross income of $1,000 or more during the year covered by this return? 3a If "Yes," has it ?led a Form 990-T for this year? If "No, provrde an explanation in Schedule 0 3b 4a At any time dunng the calendar year, did the organization have an interest in, or a Signature or other authorrty over, a ?nanCIal account in a foreign country (such as a bank account, securities account, or other ?nancral account)? 43 If "Yes," enter the name of the foreign country: See the for exceptions and filing requrrements for Form TD 9022.1, Report of Foreign Bank and FinanCIal Accounts. 5a Was the organization a party to a prohibited tax sherter transaction at any time during the tax year? 5a Did any taxable party notify the organization that it was or as a party to a prohibrted tax shelter transaction? 5b If "Yes," to line 53 or 5b, did the organization file Form 8886-T, Disclosure by Tax-Exempt Entity Regarding Prohibited Tax SheIter Transaction? 5c 6a Does the organization have annual gross receipts that are normally greater than $1 00,000, and did the organization solicrt any contributions that were not tax deductible? Ga If "Yes," the organization include every solicrtation an express statement that such contributions or were not tax deductible? . 6b 7 Organizations that may receive deductible contributions under section 170(c). a Did the organization recerve a payment in excess of $75 made partly as a contribution and partly for goods and servrces prowded to the payor" Ta If "Yes," did the orgaanation notify the donor of the value of the goods or sewices provrded? 7b Did the organization sell, exchange, or otherwrse dispose of tangible personal property for which it was requrred to ?le Form 8282? . 7c If "Yes," indicate the number of Forms 8282 ?led during the year 7:1 I Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal bene?t contract? 7e Did the organizatIOn, during the year, pay premiums, directiy or indirectly, on a personal bene?t contract? 7f 9 For all contributions of quali?ed intellectual property, did the organization ?le Form 8899 as reqwred" For contributions of cars. boats, airplanes, and other vehicles, did the organization ?le a Form 1098-C as requrred? 7h 8 Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advrsed fund maintained by a sponsoring organization, have excess busmess holdings at any time during the year? 8 9 Sponsoring organizations maintaining donor advised funds. a Did the organization make any taxable distnbutions under section 4966? 9a Did the organization make a distnbutron to a donor, donor advrsor, or related person? 9b 10 Section 501(c)(7) organizations. Enter: a Initiation fees and capital contnbutions included on Part line 12 10a Gross receipts, Included on Form 990, Part line 12, for public use of club 10b 11 Section 501(c)(12) organizations. Enter. a Gross income from members or shareholders 11a Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) 1 1b 12a Section 4947(a)(1l non?exempt charitable trusts. Is the organization tiling Form 990 in lieu of Form 1041? 12a If "Yes," enter the amount of tax-exempt interest received or accrued during the year I 12b Form 990 (2009) 932005 02?04?10 ,Formg?oizoog) CITIZENS FOR A WORKING AMERICA, INC. 27?0585219 pages Part VI Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and fora "No" response to line Ba, 8b, or TDD below, describe the Circumstances, processes, or changes in Schedule 0 See instructions Section A. Governing Body and Management Yes No 1a Enter the number of voting members of the governing body 1a 3 Enter the number of voting members that are independent 3 2 Did any officer, director, trustee, or key employee have a family relationship or a busmess relationship With any other officer, director, trustee, or key employee? 2 3 Did the organization delegate control over management duties customarily performed by or under the direct of officers, directors or trustees, or key employees to a management company or other person? 3 4 Did the organization make any Significant changes to its organizational documents smce the prior Form 990 was filed? 4 5 Did the organization become aware during the year of a material drversmn of the organization's assets? 5 6 Does the organization have members or stockholders? 6 Ta Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? 73 Are any deCISIons of the governing body subject to approval by members, stockholders, or other persons? 7b 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the followmg: a The governing body? 8a Each committee authority to act on behalf of the governing body9 8b 9 Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? If 'Yes, prowde the names and addresses in Schedule 0 9 Section B. Policies (This Section requests information about polimes not reqmred by the Internal Revenue Code.) Yes No 10a Does the organization have local chapters, branches, or af?liates? 103 If "Yes," does the organization have written poliCIes and procedures governing the actwities of such chapters, affiliates, and branches to ensure their operations are With those of the organization? 10b 1 1 Has the organization prowded a copy of this Form 990 to all members of its governing body before tiling the form" 1 1 11A Descnbe in Schedule 0 the process, if any, used by the organization to renew this Form 990. 123 Does the organization have a written conflict of interest policy? If "No, go to line 13 12a Are officers, directors or trustees, and key employees reqUIred to disclose annually interests that could give rise to conflicts? 12b Does the organization regularly and conSistently monitor and enforce compliance With the policy? If "Yes, descnbe in Schedule 0 how this is done 12c 13 Does the organization have a written whistleblower policy?7 13 14 Does the organization have a written document retention and policy? 14 15 Did the process for deterrnining compensation of the followmg persons include a rewew and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and a The organization's CEO, Executive Director, or top management of?CIal 15a Other officers or key employees of the organization 15b If "Yes" to line 15a or 15b, describe the process in Schedule 0. (See instructions.) 16a Did the organization invest in, contribute assets to, or partiCIpate in a pint venture or similar arrangement With a taxable dunng the year? 163 If "Yes," has the organization adopted a written policy or procedure requmng the organization to evaluate its partICIpation in iomt venture arrangements under applicable federal tax law, and taken steps to safeguard the organization's exempt status respect to such arrangements? 16b Section C. Disclosure 17 List the states With which a copy of this Fonn 990 is reqwred to be filed NONE 18 Section 6104 reqUires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available- Check all that apply. Own website i: Another's website Upon request 19 Describe in Schedule 0 whether (and if so, how), the organization makes Its governing documents, conflict of interest policy, and Manual statements available to the public 20 State the name, phy3ical address, and telephone number of the person who possesses the books and records of the organization' NORM CUMMINGS - 804?462?3429 388 MEADOWS DRIVE LANCASTER, VA 22503 Form 990 (2009) 932006 0204- 10 \Form 909 (2009i CITIZENS FOR HORKING AMERICA, INC . 27 ?0 585219 Page? [Part VII I Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 1a Complete this table for all persons reqmred to be listed. Report compensation for the calendar year ending With or Within the organization's tax year Use Schedule .12 if additional space is needed. 0 List all of the organization?s current officers, directors, trustees (whether indiwduals or organizations), regardless of amount of compensation Enter -0- in columns (D), (E), and (F) it no compensation was paid. List all of the organization?s current key employees See for definrtion of ?key employee 0 List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations. 0 List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations 0 List all of the organization's former directors or trustees that received, in the capaCity as a former director or tmstee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations. List persons in the followmg order. indiwdual tmstees or directors; institutional trustees; of?cers; key employees; highest compensated employees; and former such persons. Check this box if the organization did not compensate an current officer, director, or trustee. (Al (3) (C) (D) E) (F) Name and Title Average Posrtion Reportable Reportable Estimated hours (check all that apply) compensation compensation amount of per a from from related other week the organizations compensation 3?33 organization 099-MISC) from the E: a, 5 (W211 OBS-MISC) organization 75'- E: and related 3 E: organizations NORMAN CUMMINGS THOMAS BRENDAN QUINN . 3 0 . 0 . . 93200? 02-04-10 Form 990 (2009) .Form 9959 (2009) CITIZENS FOR A WORKING AMERICA, INC. 27?0585219 PageB [Part Vm Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (A) (B) (D) (E) (F) Name and title Average Posrlion Reportable Reportable Estimated hours (check all that apply) compensation compensation amount of per .6 from from related other week the organizations compensation organization from the .. organization 'g 53 and related 3 g: organizations 1b Total h? 0- 0- 0- 2 Total number of indiwduals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organization 0 Yes No 3 Did the organization list any former of?cer, director or trustee, key employee, or highest compensated employee on line 1a? If ?Yes, complete Schedule for such 3 4 For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $1 50,000? If ?Yes, complete Schedule for such 4 5 Did any person listed on line 1a receNe or accrue compensation from any unrelated organization for sewices rendered to the If "Yes, complete Schedule for such person 5 Section B. Independent Contractors 1 Complete this table for your ?ve highest compensated independent contractors that received more than $100,000 of compensation from the organization. (A) (Bl (0) Name and busmess address Description of sewices Compensation DIRECT VOICE INC . 59 2 0 SEAL LION PLACE PETITION SIGNATURE #140, CARLSBAD, CA 92010 FEES 1,300,000. 2 Total number of independent contractors (including but not limited to those listed above) who received more than in compensation from the organization 1 Form 990 (2009) 932008 02-04- 10 Form 9930 (2009) CITIZENS FOR A WORKING AMERICA, 27?0585219 Page 9 Part V?l Statement of Revenue (A) Total revenue (B) Related or exempt function revenue (Cl Unrelated busrness revenue (Di Revenue excluded from tax under sections 512, 513. or 51 4 Contributions, Igifts, ar amoun and other simi Federated campaigns Membership dues Fundraismg events Related organizations Government grants (contnbutrons) All other contributions, gifts, grants, srmilar amounts not Included above 2,372,286. Noncash contributions included in lines 1a?1t 5 Total. Add lines 1a-1f 2,372,286. am Service evenue Frog; a Busrness Code All other program sewice revenue 9 Total. Add lines 2a?2f 3 4 5 Other Revenue investment income (including interest, and other Similar amounts) Income from investment of tax-exempt bond proceeds Royatties in Real (Ii) Personal Gross Rents Less: rental expenses Rental income or (loss) Net rental income or (loss) Gross amount from sales of Securities A (in Other assets other than inventory Less: cost or other basrs and sales expenses Gain or (loss) Net gain or (loss) Gross income from events (not including of contributions reported on line 1c). See Part IV, line 18 Less: direct expenses a Net income or (loss) from events Gross income from gaming activrtres. See Part IV, line 19 Less: direct expenses Net income or (loss) from gaming activrties Gross sales of inventory, less returns and allowances Less: cost of goods sold Net income or (loss) from sales of inventory Miscellaneous Revenue Business Code 12 All other revenue Total. Add lines 11 at 1 Total revenue. See instructions. VV 2,372,286. 0. sad :9 02-04- 10 Form 990 (2009) ,Fonn990(2009) CITIZENS FOR A WORKING AMERICA Part IX Statement of Functional Expenses INC . Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D). 27-0585219 Page 10 Do not include amounts reported on lines 6b, (A) Total expenses (3) (C) 7b.8b.9b.and whome vm. assesses: 1 Grants and other to governments and organizations in the us. See Part IV, line 21 2 Grants and other assmtance to lnlelduaIS in the US. See Part IV, line 22 3 Grants and other aSSIstance to governments, organizations, and indiwduals outsrde the US. See Part lV, lines 15 and 16 4 Benefits paid to or for members 5 Compensation of current of?cers, directors, tmstees, and key employees 6 Compensation not included above, to disqualified persons (as defined under section 4958(0(1)) and persons described in section 4958(c)(3)(B) 7 Other salaries and wages 8 Pensmn plan contributions (include section 401(k) and section 403(b) employer contributions) 9 Other employee benefits 10 Payroll taxes 1 1 Fees for sewices (nonemployees): a Management 1) Legal 360,039. 360,039. Accounting Lobbying Professional fundraismg sewices. See Part IV, line 17 investment management fees 9 Other 12 Advertismg and promotion 13 Office expenses 14 Information technology 15 Royalties 16 Occupancy 17 Travel 18 Payments of travel or entertainment expenses for any federal, state, or local public of?cials 19 Conferences, conventions, and meetings 20 Interest 21 Payments to af?liates 22 DepreCIation, depletion, and amortization 23 Insurance 24 Other expenses. itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% at total expenses shown on line 25 below.) a PETITION SIGNATURE FEES 1,755,000. 1,755,000. CONSULTING FEES 141,985. 141,985. OTHER EXPENSES 9,500. 9,500. BANK FEES 374. 374. All other expenses 25 Total functional expenses. Add lines 1 through 241 Joint costs. Check here L__l if tollowmg SOP 98-2. Complete this line only if the organization reported in column (B) (pint costs from a combined educational campaign and fundraismg solicdation 932010 02-04-10 Form 990 (2009) . Form 990 (2009) CITIZENS FOR A WORKING AMERICA, INC. 27?0585219 Page 11 Wart Balance Sheet (Al (Bl Beginning of year End of year 1 Cash non-interest-bearing Savings and temporary cash investments 2 3 Pledges and grants receivable, net 3 4 Accounts receivable, net 4 5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees- Complete Part II of Schedule 5 6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of Schedule 6 3 7 Notes and loans receivable, net 7 a 8 Inventones for sale or use 8 9 Prepaid expenses and deferred charges 9 10a Land, bunldings, and equment? cost or other baSlS. Complete Part VI of Schedule 10a Less: accumulated deprecration 10b 100 1 1 Investments - publicly traded secunties 1 1 12 Investments - other secunties. See Part IV, line 11 12 13 Investments - program-related. See Pait 1V, line 1 1 13 14 Intangible assets 14 15 Other assets. See Part IV, line 11 . 15 16 Total assets. Add lines 1 through 15 (must equal line 34Accounts payable and accrued expenses 17 18 Grants payable 18 19 Deferred revenue 19 2O Taxexempt bond liabilities 20 21 Escrow or custodial account liabilrty. Complete Part IV of Schedule 21 22 Payables to current and former of?cers, directors, tmstees, key employees, highest compensated employees, and disquali?ed persons. Complete Part II of Schedule 22 23 Secured mortgages and notes payable to unrelated third parties 23 24 Unsecured notes and loans payable to unrelated third parties 24 25 Other liabilities. Complete Part of Schedule 25 26 Total liabilities. Add lines 17 through 25 0 26 0 - Organizations that follow SFAS 117. check here 9 l_l and complete 3 lines 27 through 29, and lines 33 and 34. 27 net assets 27 28 Temporanly net assets 28 '2 29 Permanently restricted net assets 29 If Organizations that do not follow SPAS 117, check here and ?6 complete lines 30 through 34. *3 30 Capital stock or pnncipal, or current funds 0 . 30 0 . 31 Paid-in or capital surplus, or land, budding, or eqmpment fund 0 . 31 0 . 32 Retained earnings, endowment, accumulated income, or other funds Total net assets or fund balances Total Inabilrties and net assets/fund balances Form 990 (2009) 932011 02-04-10 . Form 990 (2009) CITIZENS FOR A WORKING AMERICA, INC. Part XI Financial Statements and Reporting 27-0585219 Page 12 2a 3a Accounting method used to prepare the Form 990: ?11 Cash Accrual I: Other Yes No If the organIzatIon changed Its method of accountIng from a prior year or checked "Other," explaIn In Schedule 0. Were the organIzatIon's ?nanCIal statements complied or reVIewed by an Independent accountant? Were the organizatIon's ?nancial statements audrted by an independent accountant? If "Yes" to late 2a or 2b, does the organIzatIon have a commlt?tee that assumes responSIbIIrty for overSIght of the audIt, reVIew, or comleation of Its fInancral statements and selectlon of an Independent accountant? If the organlzatlon changed either Its overSIght process or selection process dunng the tax year, explarn In Schedule 0. If "Yes" to line 23 or 2b, check a box below to indicate whether the fInanCIal statements for the year were Issued on a consolrdated basrs, separate baSlS, or both: Separate basis I: Consolldated [3855 El Both consoIIdated and separate basrs As a resutt of a federal award, was the organIzatIon requrred to undergo an audrt or audIts as set forth In the Audrt Act and OMB CircularA-133" if "Yes," dId the organIzatIon undergo the reqwred audrt or audIts? If the organIzatIon dId not undergo the required audrt or audIts, epraIn why In Schedule 0 and descrIbe any steps taken to undergo such audits. 20 38 3b 932012 02-04- 10 Form 990 (2009) SCHEDULE 0 Political Campaign and Lobbying Activities 990 990452 9 arm or For Organizations Exempt From Income Tax Under section 501(c) and section 527 2 Department 01 the Treasury Complete if the organization is described below. Open to Public '"tema' Revenue Attach to Form 990 or Form QQO-EZ. See separate instructions. Inspection If the organization answered "Yes," to Form 990, Part IV, line 3, or Form 990-EZ, Part Vi, line 46 (Political Campaign Activities), then 0 Section 501(c)(3) organizations: Complete Parts IA and B. Do not complete Part I-C. 0 Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and below. Do not complete Part l-B. 0 Section 527 organizations: Complete Part I-A only. If the organization answered "Yes," to Form Part IV, line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then 0 Section 501(c)(3) organizations that have ?led Form 5768 (election under section 501 Complete Part Do not complete Part 0 Section 501(c)(3) organizations that have NOT ?led Form 5768 (election under section 501(h)): Complete Part Do not complete Part If the organization answered "Yes," to Form 990, Part IV, line 5 (Proxy Tax), then 0 Section 501(c)(4), (5), or (6) organizations: Complete Part Ill. Name of organization Employer identi?cation number CITIZENS FOR A WORKING AMERICA, INC. 27?0585219 Part Complete if the organization is exempt under section 501(c) or is a section 527 organization. 1 Provrde a description of the organization?s direct and indirect political campaign activities in Part IV. 2 Political expenditures 9 5 0 0 . 3 Volunteer hours 0 . Part I-EL Complete if the organization is exempt under section 501(c)(3). 1 Enter the amount of any eXCIse tax incurred by the organization under section 4955 2 Enter the amount of any eXCIse tax incurred by organization managers under section 4955 3 If the organization incurred a section 4955 tax, did it file Form 4720 for this year? Yes No 43 Was a correction made? Yes No If "Yes," descnbe in Part IV. Part Complete if the organization is exempt under section 501(c), except section 501(c)(3). 1 Enter the amount directly expended by the ?ling organization for section 527 exempt function activmes 0 - 2 Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activrties 9 5 0 0 . 3 Total exempt function expendrtures. Add lines 1 and 2. Enter here and on Form 1120-POL, line17b 9,500. 4 Did the ?lmg organization ?le Form 1120-POL for this yeai?? Yes No 5 Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which payments were made. For each organization listed, enter the amount paid from the filing organization?s funds Also enter the amount of political contributions receIVed that were and directly delivered to a separate political organization, such as a separate segregated fund or a polrtical action committee (PAC) If additional space is needed, prowde information in Part IV SEE PART IV FOR CONTINUATION Name Address EIN Amount paid from Amount of political ?ling organization's contributions received and funds. If none, enter and directly delivered to a separate political organization. If none, enter -0- MASSACHUSETTS INDEPENDENT PAC FOR WOBURN, MA 01801 04?3399130 9,500. 0. For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule (Form 990 or 990-EZ) 2009 LHA 932041 02?04- 10 .Schedule 0 (Form 990 or QQO-EZ) 2009 CITI ZENS FOR A WORKING AMERICA INC . Page 2 Part ll?A Complete if the organization Eexempt under section 501mm) and filed Form 57587 (election under section 501 A Check if the ?ling organization belongs to an affiliated group. Check :1 if the filing organization checked box A and "limited control" apply. . . . . Filing Affiliated group Limits on Lobbying Expenditures I ormmzahong totals (The term "expenditures" means amounts paid or incurred.) totals 1 a Total lobbying expenditures to in?uence public opinion (grass roots lobbying) Total lobbying expenditures to influence a legislative body (direct lobbying) Total lobbying expenditures (add lines 1a and 1b) Other exempt purpose expenditures Total exempt purpose expenditures (add lines 10 and 1d) Lobbying nontaxable amount. Enter the amount from the followmg table in both columns it the amount on line 1e, column or(li) is: The lobbying nontaxable amount is: Not over $500,000 20% of the amount on line 1e. Over $500,000 but not over $1,000,000 $100,000 plus 15% of the excess oveir $500,000. Over $1,000,000 but not over $1,500,000 $1 75,000 plus 10% of the excess over $1,000,000 Over $1 ,500,000 but not over $1 7,000,000 $225,000 plus 5% of the excess over $1 ,500,000. Over $1 7,000,000 $1 ,000,000 Grassroots nontaxable amount (enter 25% of line 1f) Subtract line 19 from line 1a. If zero or less, enter -0- i Subtract line 1f from line 10. If zero or less, enter -0- If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year" . El Yes C) No 4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the ?ve columns below. See the instructions for lines 23 through 2f on page 4.) Lobbying Expenditures During 4-Year Averaging Period Calendar year (of mm year beginning in, 2006 2007 2008 2009 Total 23 Lobbying nontaxable amount Lobbying ceiling amount (150% of line 2a, column(e)) Total lobbying expenditures Grassroots nontaxable amount Grassroots ceiling amount (150% of line 2d, column Grassroots lobbying expenditures Schedule (Form 990 or 990-EZ) 2009 932042 02-04-10 CITIZENS FOR A WORKING AMERICA, INC. 27?0585219 pages Part Complete if the organization is exempt under section 501 and Has NUT tiled Form 5768 (election under section 501 la) (bl Yes No Amount 1 During the year, did the filing organization attempt to in?uence foreign, national, state or local legislation, including any attempt to in?uence public opinion on a legislative matter or referendum, through the use of: Volunteers? Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? Media advertisements? Mailings to members, legislators, or the public? Publications, or published or broadcast statements? Grants to other organizations for lobbying purposes? Direct contact With legislators, their staffs, government of?cnals, or a legislative body? Rallies, demonstrations, seminars, conventions, speeches, lectures, or any Similar means? Other actiwties? If "Yes," descnbe in Part IV Total Add lines 10 through 1i 23 Did the actIVities in line 1 cause the organization to be not described in section 501(c)(3)? If "Yes," enter the amount of any tax incurred under section 4912 If "Yes," enter the amount of any tax Incurred by organization managers under section 4912 if the filin organization incurred a Section 4912 tax, did it ?le Form 4720 for this Lear? (Part Complete if the organization is exempt under section 501 section 501(c)(5), or section h- 501(c)(6). Yes No 1 Were substantially all (90% or more) dues received nondeductible by members? 1 2 Did the organization make only in-house lobbying expenditures of $2,000 or less? 2 3 Did the oranization aree to ca over lobb in - and olitical - nditures from the rior ear? 3 Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part ill-A, lines 1 and 2 are answered "No" OR if Part line 3 is answered "Yes." 1 Dues, assessments and similar amounts from members 1 Part Ill?B Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid). a Current year 23 Carryover from last year 2b Total 2c 3 Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues 3 4 If notices were sent and the amount on line 20 exceeds the amount on line 3, what portion of the excess does the organization agree to canyover to the reasonable estimate of nondeductible lobbying and political expenditure next year? 4 5 Taxable amount of lobbying and political expenditures (see 5 [Part IV Supplemental Information Complete this part to prowde the reqUIred for Part l-A, line 1; Part I-B, line 4; Part l-C, line 5; and Part line 1i Also, complete this part for any additional information PART IwA.r LINE 1: CONTRIBUTION TO MASSACHUSETTS INDEPENDENT PAC FOR WORKING FAMILIES PART I-C CONTINUATION FOR INCOMPLETE INFORMATION: MASSACHUSETTS INDEPENDENT PAC FOR WORKING FAMILIES 400 WEST CUMMINGS PARK WOBURN, MA 01801 Schedule (Form 990 or 990-EZ) 2009 932043 02-04-10 OMB No 1545-0047 - SCHEDULE 0 Supplemental Information to Form 990 it i- - (Form 990) Complete to provide information for responses to speci?c questions on 2 Department of the Treasury Form 990 or to provide any additional information. open t9 public "new. Revenue 3mm Attach to Form 990. Inspection Name of the organization Employer identi?cation number CITIZENS FOR A WORKING AMERICA, INC. 27-0585219 FORM 990, PART I. LINE 1, DESCRIPTION OF ORGANIZATION MISSION: EFFORTS, 2) BY PARTICIPATING IN THE PUBLIC POLICY ARENA, AND 3) BY PROVIDING EDUCATIONAL SERVICES TO THE GENERAL PUBLIC. FORM 990, PART VI, SECTION B, LINE 11: THE POLICY IS TO SUBMIT A DRAFT OF THE ANNUAL FORM 990 AND RELATED SCHEDULES AND FORMS TO THE BOARD OF DIRECTORS PRIOR TO FILING THE FORM 990 WITH THE IRS. OFFICIAL ACTION BY THE BOARD IS NOT REQUIRED IN ORDER FOR FORM 990 TO BE FILED, BUT EACH BOARD MEMBER IS ENCOURAGED TO REVIEW AND APPROVE THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C: EACH INTERESTED PERSON MUST DISCLOSE POSSIBLE OR ACTUAL CONFLICT OF INTEREST. AFTER DISCLOSURE, THE BOARD SHALL DECIDE IF A CONFLICT EXISTS. IF A CONFLICT DOES EXIST, THE BOARD WILL DETERMINE IF THE TRANSACTION CAUSING THE CONFLICT COULD BE AVOIDED BY STRUCTURING THE TRANSACTION WITH A PARTY THAT IS NOT AN INTERESTED PARTY. IF A MORE ADVANTAGEOUS TRANSACTION IS NOT REASONABLY POSSIBLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE BOARD WILL VOTE ON WHETHER THE TRANSACTION IS IN THE BEST INTEREST. FORM 990, PART VI, SECTION C, LINE 19: IT IS THE POLICY TO FULLY COMPLY WITH ALL FEDERAL AND STATE DISCLOSURE REQUIREMENTS RELATING TO IRS FORMS. THE ORGANIZATION WILL FULFILL REQUESTS FOR APPLICABLE FORMS IN ACCORDANCE WITH THE PUBLIC DISCLOSURE REQUIREMENTS. GOVERNING DOCUMENTS SUBJECT TO PUBLIC DISCLOSURE RULES WILL BE MADE PUBLICLY AVAILABLE AS APPLICABLE LAW MAY REQUIRE. OTHERWISE, THE DOCUMENTS WILL BE PROVIDED AT LHA For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule 0 (Form 990) 2009 932211 02-03-10 . SCHEDULE 0 Supplemental Information to Form 990 (Form 990) Complete to provide information for responses to speci?c questions on 2 Form 990 or to provide any additional information. Open to Public Attach to Form 990. Inspection Name of the organization Employer identi?cation number CITIZENS FOR A WORKING AMERICA, INC. 27-0585219 THE DISCRETION OF THE PRESIDENT OF THE ORGANIZATION AFTER CONSULTATION WITH PROFESS IONAL ADVISERS . LHA For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990. Schedule 0 (Form 990) 2009 932211 02-03-10 ?Form 8868 Application for Extension of Time To File an (Rev. January 2011) Exempt Organization Return OMB No. 1545-1709 Internal 51:0th File a separate application for each return. 0 If you are filing foran Automatic 8-Morith Extension, complete onlyPart and check this box A 0 If you are tiling for an Additional (Not Antoinette) 3-Month Extension, complete only Part II (on page 2 of this form). Do not complete Part II unless you have already been granted an automatic 3-month extension on a previously filed Form 8868. Electronic ?ling le~lile}. You can electronically ?le Form 8868 it you need a 3-month automatic extension of time to tile (6 months for a corporation required to ?le Form 990-1). or an additional (not automatic) 3-month extension of time. You can electronically ?le Form 8868 to request an extensmn of time to tile any of the forms listed in Part I or Part II with the exception of Form 8870, Information Return for Transfers Associated With Certain Personal Benefit Contracts. which must be sent to the IRS in paper format (see instructions). For more details on the electronic ?ling of this form. Visit Emir/stile and click on e??le for Charities Nonpro?ts. Automatic 3-Month Extension of Time. oniy submit gginai (no copies needed)._ A corporation reqUIred to ?le Form 990-T and requesting an automatic 6-month extension - check this box and complete Part I only All other corporations (including 1120-0 ?lers), partnerships, and trusts must use Form 7004 to request an extension of time to ?le income tax returns. Type or Name of exempt organization Employer identi?cation number print CITIZENS FOR A WORKING AMERICA, INC .. 27?05852 19 21:31:; Number. street, and room or suite no. If a P.O. box. see instructions. ?aws?; 1 3 1 NORTH LUDLOW STREET NO . 3 15 melons City. town or post of?ce. state. and ZIP code. For a foreign address, see instructions- DAYTON, OH 45402 Enter the Return code forthe retum that this application is tortilla a separate appfication foreach return) .. . Application Return Application Is For 990 1041-A Form 401 or QQO-T other 0 Thebooksareinthecareof Telephone No.> FAX No. 0 lfthe organization does not have an office or place of business In the United States. check this box 0 If this is for a Group Return. enter the organization's four digit Group Exemption Number (GEN) - ll this is for the whole group. check this box . Ifit isfotpartofthemuglcheckthis box andattach alist withthenames and EleotalI mambersthe extension isfor. 1 I request an automatic 3-month (8 months for a corporation required to ?le Form 990-1") extension of time until MAY ?le the exempt organization ietum for the organization named above. The extension is for the organization's return for: calendar year or taxyearbeginning OCT 1 SEP 30, 2010 2 If the tax year entered in line 1 '3 for less than 12 months. check rem: I: Initial return [3 Final return I: Change in accounting period 3a If this application is for Form QQO-BL. 990-PF. 990T. 4720. or 6069. enter the tentative tax, less any nonrefundable credits. 3a 3 0 . If this application is for Form QQO-PF, 990T, 4720. or 6069. enter any refundable credits and estimated tax path made. Include any prior year overpayment allowed 3 a credit. 3b 0 Balance due. Subtract line 3b from line 3a. Include your payment with this form, if required. usin onic Federal Tax ent em). See in_s_tructions_._ 3c 5 0 - Caution. It you are gg'ng to make an electronic fund withdrawal with this Form 8888I see Form 8453-EO and Form BBTQ-EO for payment instructions. LHA For Paperwork Reduction Act Notice, see Instructions. Form 8888 (Rev. 1-2011) 923841 01-03-11 Form 8868 (Rev. 1-20m Piage_2 'o are ?ling ioren Additional (th Automatic) 3-Month Extension. complete only Part ii and check th box ., Note. Only complete Pelt ii if you have already been granted an automatic 3-month extension on a previously ?led Form 8868. 0 If you are ?ling for an Automatic 3-Month Extension. complete only Part I (on page 1). Additional (Not Automatic) 3-Month Extension of Time. Only file the original (no copies needed). Name of exempt organization Employer identi?cation number Type or mint EITIZENS FOR A WORKING AMERICA, INC. 27?05852 19 Fileby the Number. street. and room or suite no. If a P.O. box. see instructions. 1 3 1 NORTH LUDLOW STREET NO 3 1 5 return Sun City. town or post of?ce. state. and ZIP code. For a foreign address. see instructions. ?Wm DAYTON, OH 45402 Enter the Return code for the return that this application In for (?le a separate application foreach return) .. . .. Application Hemrn Application For code 01 4 04 Form or 06 12 Do not complete Part II it you were not alreag Enter! an automatic 3-month extension on It MM ?led Form 8803- . 0 The books arein thecareof NORM CUMMINGS TelephoneNo.> 937?222?0131 norm; 0 lfthe organization does not have an of?ceor placedbusinees in the United States. dieckthis box . . 0 If this is for a Group Return. enter the organization's four digit Group Exemption Number (GEN) . it this is for the whole group. check this box El . lfit Bforthofthe box i: andattachalietwiththenames and Eleofall memberstheextension later. 4 request an additional 3-month extension of time until AUGUST 1 5 2 1 1 5 Forcalendaryear .orothertaxyearbeginning OCT 1 2009 SEP 30: 2010 a If the tax year entered in line 5 is for less than 12 months. check reason: l:l Initial return Final return [3 Change in accounting period 7 State in detail why you need the extension ADDITIONAL TIME IS NECESSARY IN ORDER TO PREPARE A COMPLETE AND ACCURATE RETURN Be it this application is for Form 990-BL. 990-PF. 990T. 4720. or 6069. enter the tentative tax. less any nonreiundable credits. See instructions. wtie 0 - If this application for Form 990-PF. 99in. 4720. or 6069. enter any refundable credts and estimated tax payments made. Include any prior year overpayment allowed as a credit and any amount paid previously Form case. at: 0 - Balance due. Subtract line 8b from ?ne 8a. Include your payment with this form. if required, by using El?Tps (Electronic Federal Tax Payment System). See instructions. so 3 0 - Signature and Veri?cation Under penalties of pariury. I declare that have examined this tonn. including accompanying schedules and statements. and to the host of my lttlollrledgil and belief. it is true. correct. and com late. and that I am authorized to prepare this form. celeb 379/? also (Flev. 1-2011) 923842 01-03-11