citizennmlimrg 990-EZ Short Form Under section 501(c), 527, or 4947(a)(1) ot the Internal Return of Organization Exempt From Income Tax Revenue Code (except black lung benefit trust or private foundation) Sponsoring organizations of donor adVised funds, organizations that operate one or more hospital faCIlities, F3 and certain controlling organizations as de?ned in section 512(b)(13) must file Form 990 (see Instructions) All other organizations With gross receipts less than $200,000 and total assets less than $500,000 %t of theTreasury at the end of the year may use this term mama! Revenue semoe The organization may have to use a copy of this return to satisfy state reporting requrrerrients (9?73 For the 2011 calendar year, or tax year beginning Saw Check if applicable 5% ME 9 Address change Name change Initial return Terminated Amended return Application pending OMB No.1545-1150 Open to Public lnspec?on . 2011, and ending .201! Name of organization Sam Dizems Fig-t Oman Godunmn?r Employer identi?cation number a? 1S- Number and street (or 0 box, if mail is not delivered to street address) ME Sr. Room/suns Telephone number 01m US City or town, state or country. and ZIP 4 Demo. Ck 75 C_o Group Exemption Number Check 5 Add lines 50, 6c, and 7b, to line 9 to determine gross receipts If gross receipts are $200,000 or more, or if total assets (Part II, I Accounting Method: Website: Tax-exempt status (check only one) $501 El 501 Cash Accrual Other (speCIfy) (insert no.) 4947(a)(1) or 527 Check if the organization is not reqmred to attach Schedule 8 (Form 990, 990-EZ, or 990-PF) if the organization is not a section 509(a)(3) supporting organization or a section 527 organization and its gross receipts are normally not more than $50,000. A Form 990-EZ or Form 990 return is not reqmred though Form 990-N (e?postcard) may be requued (see instructions). But if the organization chooses to file a return, be sure to file a complete return. line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ . . . . 0 Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I.) Check if the organization used Schedule 0 to respond to any question in this Part Contributions, gifts, grants, and similar amounts received . 1 (9 2 Program service revenue including government fees and contracts 2 3 Membership dues and assessments . 3 0 4 investment income . . . . . . . . . . . . . . 4 0 5a Gross amount from sale of assets other than inventory 5a 0 Less: cost or other and sales expenses . . . . . . . . 5b 0 Gain or (loss) from sale of assets other than inventory (Subtract line 5b from tine 5a) . 5c 0 6 Gaming and fundraising events a Gross income from gaming (attach Schedule if greater than $15,000). .. sa 0 Gross income from fundraismg events (not including of contnbutions from fundraising events reported on line 1) (attach Schedule if the sum of such gross income and contributions exceeds $15,000) . 3b (9 Less: direct expenses from gaming and fundraising events . . . 6c 0 Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract 6d 0 7a Gross sales of inventory, less returns and allowances Less: cost of goods sold . . . . . . . . . . . a) . . Gross profit or (loss) from sales of inventory (Subtract line 7 gr- line 7a) . . 7c f) 8 Other revenue (describe in Schedule Total revenue. Add lines Grants and similar amounts paid (list in Schedule 0) 10 0 11 Benefits paid to or for members . . . . . . . . 11 0 3 12 Salaries, other compensation, and employee benefits . . . 12 2 13 Professional fees and other payments to independent contractors . 13 =3 g. 14 Occupancy, rent, utilities, and maintenance 14 ?93, IJ-I 15 Printing, publications. postage, and shipping . 15 a 16 Other expenses (describe in Schedule Total expenses. Add lines 10 through Excess or (deficit) for the year (Subtract line 17 from line Net assets or fund balances at beginning of year (from line 27, column (must agree With 5 end-of?year figure reported on prior year's return6/12 ?5 20 Other changes in net assets or fund balances (explain in Schedule 0) . . 20 0' 21 Net assets or fund balances at end of year. Combine lines 18 through 20 . 21 CL For Paperwork Reduction Act Notice. see the separate instructions. Cat No 10642l Farm (2011) 2L Form 990-EZ (2011) Page 2 Part II . Balance Sheets. (see the instructions for Part II.) Check if the (Eganization used Schedule 0 to respond to any question in this Part II . El (A) Beginning of year (B) End of year 22 Cash, savings, and investments 22 23 Land and buildings . . . . . . . 23 24 Other assets (describe in Schedule 0) 24 f) 25 Total assets . . . . . . . . . . . 25 f) 26 Total liabilities (describe in Schedule Net assets or fund balances (line 27 of column (8) must agree with line 21) 27 0 Statement of Program Service Accomplishments (see the instructions for Part . . xpenses Check if the organization used Schedule 0 to respond to any question in this Part . . El (Requ?ed forsecmn What is the organization's primary exempt purpose? c: 501(c)(3) and Describe the organization's program seNlce accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner. describe the services provided, the number of persons benefited, and other relevant information for each program title. organizations and section 4947(a)(1) trusts. optional for others.) 28 . (Grants -) If this amount includes foreign-grants, check here El 28a 29 If this-amount inclu-des-toreign grants, check here 29a 30 [It-this amountihcludesforeiglgrants, check . . El 30a 0 31 Other program sewices (describe in Schedule (Grants If this amount Includes foreign grants, check here . . . . 31a 32 Total program service expenses (add lines 28a through 31aCheck if the organization used Schedule 0 to respond to any question in this Part IV List of Officers, DirectorsI Trustees, and Key Employees. List each one even if not compensated. (see the instructions for Part IV.) El Reportable Health benefits. compensation (Forms Title and average hours per week devoted to posmon Name and address benefit plans, and (ill not paid. enter -0-) deferred compensation contributions to employee (9) Estimated amount of other compensation 6 1'37? ?DV?di - (mg. as: e_ ?Hoaxgm?lsyutec-Emma Form 990-EZ (2011) Form ego-52 (2011) Other Information (Note the Schedule A and personal benefit contract statement requirements in the instructions for Part V.) Check if the organization used Schedule 0 to respond to any question in this Part Page 3 El 33 41 42a Did the organization engage In any signi?cant activity not previously reported to the If ?Yes,? provide a Yes No detailed description of each actiwty in Schedule Were any Significant changes made to the organizing or governing documents? if "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization's name. Otherwise, explain the change on Schedule 0 (see instructionsDid the organization have unrelated business gross income of $1,000 or more during the year from business actIVIties (such as those reported on lines 2, 6a, and 7a, among others?Yes,? to line 35a, has the organization filed a Form 990-T for the year? If provide an explanation in Schedule 0 35b Was the organization a section 501(c)(4), 501 or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax reqUirements during the year? If "Yes," complete Schedule C, Part . . 35c Did the organization undergo a liquidation, dissolution, termination, or significant dispOSItion of net assets during the year? If "Yes," complete applicable parts of Schedule . . . . . . . . . . . . 36 Enter amount of political expenditures, direct or indirect, as described in the instructions. I 37a I I Did the organization file Form 1120-POL for this year37b Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were A any such loans made in a prior year and still outstanding at the end of the tax year covered by this return? 333 If ?Yes,? complete Schedule L, Part II and enter the total amount involved 38b 0 Section 501(c)(7) organizations. Enter: Initiation fees and capital contributions included on line Gross receipts, included on line 9, for public use of club faCIlities . . . . . . . 39b 0 Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under: section 4911 section 4912 section 4955 Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year, or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or If ?Yes,? complete Schedule L, Part I . 40b Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 0 Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 400 reimbursed by the organization . . . . . . . . . . . . . . . All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If ?Yes,? complete Form 8886-T. . Elm?? List the states with which a copy of this return is filed. 95A in in The organization's boo are in care of Telephone no. - - ?rms; Located at At any time during the calendar year, did the organizatio have an interest in Or a Signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other fmancral account)? If ?Yes,? enter the name of the foreign country: See the instructions for exceptions and filing requirements for Form TD 90-221, Report of Foreign Bank and Financial Accounts. At any time during the calendar year, did the organization maintain an office outside the . If ?Yes,? enter the name of the foreign country: Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041 ?Check here and enter the amount of tax-exempt interest received or accrued during the tax year . Did the organization maintain any donor advised funds during the year? If ?Yes,? Form 990 must be completed instead of Form 990-Did the organization operate one or more hospital faculties during the year? If ?Yes,? Form 990 must be completed instead of Form 990-Did the organization receive any payments for indoor tanning services during the year'Yes' to line 440, has the organization filed a Form 720 to report these payments? If prowde an explanation in Schedule 0 . . . . . Did the organization have a controlled entity within the meaning of section 512(b)(13Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If ?Yes,? Form 990 and Schedule may need to be completed instead of Form 990-EZ (see instructions 4345b Form 990-EZ (27311) Form Page 4 - Yes No 46- Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If ?Yes,? complete Schedule C, Part Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only. All section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47?49b and 52, and complete the tables for lines 50 and 51. Check if the organization used Schedule 0 to respond to any question in this Part Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax year? If ?Yes,? complete Schedule C, Part the organization a school as described in section 170(b)(1)(A)(li)7 If ?Yes,? complete Schedule . . . . 48 \f 49a Did the organization make any transfers to an exempt non-charitable related organization"Yes," was the related organization a section 527 organizationComplete this table for the organization's five highest compensated employees (other than officers, directors. trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None." Health benefits, contributions to employee Estimated amount of benefit plans, and deferred other compensation compensation Title and average to) Reportable hours per week compensation devoted to posmon (Forms Name and address of each employee paid more than $100,000 . . . . . . . . . . . . . . . . . . . . . . . . Total number of other employees paid over $100,000 . . . . 51 Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none. enter "None." Name and address of each independent contractor paid more than $100,000 Type of serwce Compensation Total number of other independent contractors each receiving over $100,000 . . 52 Did the organization complete Schedule Note: All section 501 organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A . Yes No Under penalties of periury. I declare that have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete (other than of?cer) is based on all information of which preparer has any knowledge gait-Qt)" In Here in,? ?Gowbr?iokoiya,i CED ?lb(20l7/ Sign Signature of of?cer Type or name and title Paid Print/Type preparers name Preparer?s signature Date Check If Preparer self-employed use only Firm's name Firms EIN Finn's address Phone no May the IRS discuss this return with the preparer shown above? See instructions Yes No Form 990-EZ (2011) SCHEDULE A (Form 990 or 990-EZ) Department of the Treasury lntemal Revenue Sewice OMB No 1545-0047 Public Charity Status and Public Support Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust. Attach to Form 990 or Form 990-EZ. See separate instructions. Open to Public Inspection Nam Employer Identi?cation number 3r??&ns ?Cw 86m @DMi/tmeyd" 61?? else? 9.6 Reaso?? for Public Charity Status (All organizations must complete this part.) See instructions. The organization is not a private foundation because it is: (For lines 1 through 11. check only one box.) 1 A church. convention of churches. or association of churches described in section 2 A school described in section (Attach Schedule E.) 3 A hospital or a cooperative hospital service organization described in section 4 A medical research organization operated in conjunction With a hospital described in section Enter the hospital?s name, city, and state: 5 E) An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section (Complete Part II.) 6 A federal. state, or local government or governmental unit described in section 7 An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section (Complete Part II.) 8 A community trust described in section (Complete Part ll.) 9 An organization that normally receives: (1) more than 33?/3% of its support from contributions, membership fees, and gross receipts from actiwties related to its exempt functions?subject to certain exceptions. and (2) no more than 33?/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30. 1975. See section 509(a)(2). (Complete Part 10 An organization organized and operated exclusively to test for public safety. See section 509(a)(4). 11 organization organized and operated exclusively for the benefit of, to perform the functions of, or to cany out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h. a Type I Type II El Type Ill?Functionally integrated Type Ill?Other By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). If the organization received a written determination from the IRS that it is a Type I, Type II, or Type supporting organization.checkthisbox. 9 Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons? A person who directly or indirectly controls. either alone or together with persons described in (ii) and below, the governing body of the supported organization(ii) A family member of a person described in above35% controlled entity of a person described in or (in aboveProvide the followmg information about the supported organization(s). Name of supported (ii) EIN Type of organization (iv) Is the organization (it) Did you notify (vi) Is the (vii) Amount of organization (described on [mes 1-9 in col 0) listed in your the organization in organization In col support above or (RC sealer. governing document? col of your organized in the (see instructions? suppo'(Al (B) (C) (D) (E) Total For Paperwork Reduction Act Notice. see the Instructions for Cat No. 11285F Schedule A (Form 990 or 990-EZ) 2011 Form 990 or 990-EZ. Schedule A (Form 990 or 990-EZ) 2011 Ver5ion A, cycle 1 Page 2 . Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7. or 8 of Part I or if the organization failed to qualify under Part If the organization fails to qualify under the tests listed below, please complete Part Section A. Public Support Calendar year (or ?scal year beginning in) 1 6 2007 2008 2009 2010 2011 Total Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants") . Tax revenues leVIed for the organization's benefit and either paid to or expended on its behalf The value of services or faculties furnished by a governmental unit to the organization without charge . Total. Add lines 1 through 3 . The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column . Public support. Subtract line 5 from line 4. Section B. Total Support Calendar year (or fiscal year beginning inSection C. Computation of Public Support Percentage 2007 2008 2009 2010 2011 Total Amounts from line 4 Gross income from interest, dividends, payments received on securities loans. rents, royalties and income from Similar sources Net income from unrelated business activities, whether or not the busmess is regularly carried on Other income. Do not Include gain or loss from the sale of capital assets (Explain in Part IVTotal support. Add lines 7 through 10 Gross receipts from related actIVIties, etc. (see instructions) . . . . 12 First five years. if the Form 990 is for the organization?s first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here . . . 14 15 16a 17a 18 Public support percentage for 2011 (line 6, column lelded by line 11, column 14 Public support percentage from 2010 Schedule A. Part II. line 9,3113% support test?2011. If the organization did not check the box on line 13. and line 14 is 33?ia% or more, check this box and stop here. The organization qualifies as a publicly supported organization . . . . . . . . . . . 331/:i% support test?2010. If the organization did not check a box on line 13 or 16a, and line 15 is or more. check this box and stop here. The organization qualifies as a publicly supported organization . . . . . . . 10%-facts-and-circumstances test?2011. If the organization did not check a box on line 13, 16a. or 16b, and line 14 IS 10% or more, and if the organization meets the ?facts-and-circumstances" test. check this box and stop here. Explain in Part IV how the organization meets the ?facts-and-circumstances? test. The organization quali?es as a publicly supported organization . 10%-facts-and-circumstances test?2010. If the organization did not check a box on line 13. 16a, 16b, or 17a. and line 15 is 10% or more, and if the organization meets the ?facts?and-circumstances" test. check this box and stop here. Explain in Part IV how the organization meets the ?facts-and-circumstances? test. The organization qualifies as a publicly supportedorganization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Private foundation. If the organization did not check a box on line 13. 16a. 16b. 17a. or 17b. check this box and see El Schedule A (Form 990 or 2011 Schedule A (Form 990 or 990-EZ) 2011 Page 3 I Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.) Section A. Public Support Calendar year (or ?scal year beginning in) 2007 2008 2009 2010 2011 Total 1 Gifts. grants. contributions, and membership fees 0 0 received. (Do not include any 'unusual grants.') 6 2 Gross receipts from admissions, merchandise sold or services performed, or faculties furnished in any activity that is related to the organization's tax?exempt purpose . 3 Gross receipts from activrties that are not an unrelated trade or business under section 513 4 Tax revenues levied for the organization?s benefit and either paid to or expended on Its behalf 5 The value of services or facilities 0 furnished by a governmental unit to the 0 0Q organization without charge . 6 Total. Add lines 1 through 5 . 7a Amounts included on lines 1, 2, and 3 received from disqualified persons 000? Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year (O E) (0 V) 0 A ,b?obcbosbool o?ocz? (3me Addlines'i'aandTb . . . . . . '0 (9 8 Public support (Subtract line 7c from Section B. Total Suppo Calendar year (or fiscal year beginning in) 2007 2008 2009 2010 2011 Total 9 Amounts from line6 . . . . . 103 Gross income from interest, dividends, 6 payments received on securities loans, rents, C) 6 royalties and income from similar sources . Unrelated business taxable income (less section 511 taxes) from businesses 0 0 acquired after June 30, 1975 . Add lines 10a and 10b 11 Net income from unrelated busmess (9 LO 0 actIVities not included in line 10b, whether a or not the business is regularly carried on 12 Other income. 00 not include gain or loss from the sale of capital assets (Explain in Part IVTotal support. (Add lines 9, 10c, 11, A and12.) 14 First five years. If the Form 990 is for the organization?s first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here . . . . . . . . . . . . . . . . . . . . . . . . . Section C. Computation of Public Support Percentage 15 Public support percentage for 2011 (line 8, column (1) divided by line 13, column . . . . . 15 16 Public support percentage from 2010 Schedule A, Part line Section D. Computation of Investment Income Percentage 17 Investment income percentage for 2011 (line 10c, column (1) diVided by line 13, column . . . 17 18 Investment income percentage from 2010 Schedule A, Part line 19a 33?ra% support tests?2011. If the organization did not check the box on line 14. and line 15 is more than 33?n%, and line 17 is not more than 33?n%, check this box and stop here. The organization quali?es as a publicly supported organization . 33?ia% support tests-2010. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33?r3%, and line 18 is not more than 33?ra%. check this box and stop here. The organization quali?es as a publicly supported organization 20 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions Schedule A (Form 990 or 990-51) 2011 Schedule A (Form 990 or 990-EZ) 2011 Page 4 ?upplemental information. Complete this part to provide the explanations required by Part ll, line 10; Part II. line 17a or 17b; and Part Ill, line 12. Also complete this part for any additional information. (See instructions). i Schedule A (Form 990 or BSD-E2) 2011