2017

EXTENDED TO NOVEMBER 15,
Form

ON9 No 1545-0047

Return of Organization Exempt From Income Tax

990

owartnwdOfUW T uy
bvwmf Revenue Sffvlw

Under section 501(c), 527, or 4947( a)(1) of the Internal Revenue Code ( except private foundations)
^ Do not enter social security numbers on this form as it may be made public.
I

NO- Information about Form 990 and its Instructions Is at www. 6s ov/form99O.
and ending
A For the 2016 calendar year, or tax year beginning

nw
B c
app6cab

D Employer identification number

C Name of organization

= ^ge

CONVENTION OF STATES ACTION

1^w

Doin g business as
Number and street (or P.O. box if mail is not delivered to street address )

Q,Ron! ,,

100 CONGRESS AVE

oe
Q^°s°

City or town, state or province , country , and Z3P or foreign postal code
AUSTIN, TX
78701

O^DOO°^'
''°

F Name and address of principal officer.MARK
SAME AS C ABOVE

I Tax-exem pt status :

501(c)( 3)

LXJ 501(c) (

47-2245708
Room/suite E Telephone number
540-441-7227
12 000
4 , 929 , 0
G Gtow mceiats s
H(a) Is this a group return

MECKLER

for subordinates?

[=Yes ® No

H(b) ae an ^am^uae u+a,ded?EJYes =No

)4 (insert no .)

J Website: ^ WWW. COSACTION. COM
Trust
K Form of groan ®hon: LXJ Corporation

Association

4947( x)(1) or

527

It 'No ,' attach a list. (see instructions)

H(c) Grou p exemption number ^
L Year of formation : 20 1 41 M State of legal domicile: TX

L-J Other ^

m
c

1

Briefly describe the organization 's mission or most signdicant activities: TO ADVOCATE FOR A
CONSTITUTIONALLY LIMITED GOVERNMENT.

ffi

2

Check this box ^ L-J if the organization discontinued its operations or disposed of more than 25% of its net assets.

3
4

Number of voting members of the governing body (Part VI , One 1a)
Number of Independent voting members of the governing body (Part VI , One 1 b)

5

Total number of ind ividuals employed in calendar year 2016 ( Part V, line 2a)

6

Total number of volunteers (estimate if necessary)

1w

2016

Open to Public
Inspection

,,,,,,, ,,..
„ ., „ , ,,,,,, ,,, „ , ,., „ ,

7 a Total unrelated business revenue from Part VIII, column (C), line 12

..

..

... ..... .............. .

b Net unrelated business taxable income from Form 990-T, line 34

3
4

4

5

0
45000

6

0 .

7a

0 .

7b

B

Contributions and grants (Part Vlll , line 1 h)

Prior Year
3 , 220 , 865.

re

9

Program service revenue (Part VIII , One 2g)

.

0 .

= 9

10

Investment income (Part VIII , column (A), lines 3, 4, and 7d) , _, ,,., ..

0.

0.

11
12

Other revenue (Part VIII , column (A), lines 5, 6d, Sc , 9c, 10c, and 11e)
Total revenue • add lines 6 throug h 11 must equal Part Vill, column
, line 12

13

Grants and similar amounts paid (Part IX, column (P) , lines 13)

14

Benefits paid to or for members (Part IX, column (A), line 4)

15

Salaries , other compensation , employee benefits (Part IX, column (A), lines 5-10)'.

fO

16a Professional fundraising fees (Part IX, column (A), line 11 e)
b Total fundraising expenses art IX, column (D), line 25)

W

17

Other expenses (Part IX, column (A), lines 11 a- 11 d, 11 f-24e)

16

ex nses . Add lines 13.17 must
Total expenses

19

Revenue

y

.... _._

Current Year

4,903,002.

0.

76-, 0

5 .

4,92 9 ,01 4.

0 .

0 .

505,584.
, 693 •

1,15 3 , 5 3 2 .

3, 2 20, 8

- 173

6 40,523.

1 , 386 , 080 .
01 , 7 3 2 .

1 , 777 ,

9 8 1 , 009 . ---3 ,

ual

ex penses . Subtract line 8 fro

^ E'
-

20

Total assets (Part X, line 16)

21

Total liabilities (Part X, Tine 26)

22

Net assets or fund balances Subtract line 21 . from line 2

-

239, 85 6 .

Beginning of Current Year
7 .
.

... V .,.... (? j

3 .

1 , 988

1,357,026.
End of Year
0 ,
.

^
1R
0'

2 37

,

00 .

1, 594,42 6.

Lw d- U-^ , U P
I rara u 1 0ignawre DrocK
Under penalties of perjury, I declar tha I have examined th' return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct, and comple
ati a
r (a er an officer) is based on all information of which preparer has any knowledge.
ig

Sign
Here

Paid
Preparer
Use Only

e a a ce

K MECKL R ,
Type or print name an
e

ae
CEO

Print/Type preparer's name
Preparer' s signs
Dax+r*^
ENNIS K. WEISS, CPA
D. K. WEISS & ASSOCIATES
Firm ' s name
Fiirm's address , 4660 N. BRETON COURT, S
KENTWOOD, MI 49508

63200 1 11-11 -10

.

295,597.

LHA For Paperwork Reduction Act Notice , see the

 CONVENTION OF STATES ACTION
Form 990 2016
Part III Statement of Program Service Accomplishments
1

47- 2245708

Pa e2

Check if Schedule 0 contains a response or note to any line in this Part III
Briefly describe the organization 's mission:

TO ADVOCATE FOR A CONSTITUTIONALLY LIMITED GOVERNMENT.

2

3
4

4a

Did the organization undertake any significant program services during the year which were not listed on the
prior Form 990 or 990 -EZ?
=Yes ® No
If "Yes ,' describe these new services on Schedule 0.
Did the organization cease conducting , or make significant changes in how it conducts , any program services?
=Yes ® No
If "Yes," describe these changes on Schedule 0
Describe the organization 's program service accomplishments for each of its three largest program services, as measured by expenses.
Section 501 (c)(3) and 501 (c)(4) organizations are required to report the amount of grants and allocations to others , the total expenses, and
revenue , if an y, for each p ro g ram service re ported.
(Code

) (Expenses $

1,85 2 , 2 6 2.

including grants of $

) (Revenue $

COSA ADVOCATES FOR A RETURN TO THE ORIGINAL VISION OF A LIMITED FEDERAL
GOVERNMENT THAT IS OF, BY AND FOR THE PEOPLE. THIS WILL BE ACCOMPLISHED
THROUGH AN ARTICLE V CONVENTION OF STATES.

4b

(Code

) (Expenses $

including grants of $

)

4c

(Code

) (Expenses $

including grants of $

) (Revenue $

4d

Other program services (Describe in Schedule 0)

4e

Total program service expenses ^

(Expenses $

including grants of $

)

(Revenues

(Revenue $

1,852,262.
Form 990 (2016)

632002 11-11-16

15020926 798302 1381A

3
2016. 04020 CONVENTION OF STATES ACTION 1381A1

 47-2245708

CONVENTION OF STATES ACTION
= rm99o 2016
Part IV Checklist of Required Schedules

Pa e3
Yes

1

No

Is the organization described in section 501 (c)(3) or 4947(a)(1) (other than a private foundation)?
If 'Yes,' complete Schedule A

2
3

-

2

public office? If 'Yes,' complete Schedule C, Part l

3

-

Section 501(c)(3) organizations . 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 Il
5 Is the organization a section 501 (c)(4), 501(c)(5), or 501 (c)(6) organization that receives membership dues, assessments, or
similar amounts as defined in Revenue Procedure 98.19? If 'Yes,' complete Schedule C, Part 1//
6 Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to
provide advice on the distribution or investment of amounts In such funds or accounts? If 'Yes," complete Schedule D, Part /
7 Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes,' complete Schedule D, Part 11
8 Did the organization maintain collections of works of art, historical treasures, or other similar assets? If 'Yes,' complete
Schedule D, Part 111
9 Did the organization report an amount in Part X, line 21, for escrow or custodial account liability, serve as a custodian for
amounts not listed in Part X, or provide credit counseling, debt management, credit repair, or debt negotiation services'?
If 'Yes,' complete Schedule D, Part IV
10 Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent
endowments, or quasi-endowments' If 'Yes,' complete Schedule D, Part V
11 If the organization's answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X
as applicable.
a Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes,' complete Schedule D,

X

I

Is the organization required to complete Schedule B, Schedule of Contnbutors2
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for

X
X

4

Part VI

4
5

X

6

X

7

X

8

X

9

X

10

X

I la

X

11b

X

11c

X

11d
11e

X
X

b 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 16'? If 'Yes,' complete Schedule D, Part VII

c 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 VIII

d 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
e Did the organization report an amount for other liabilities in Part X, line 25? If "Yes,' complete Schedule D, Part X
f Did the organization's separate or consolidated financial statements for the tax year include a footnote that addresses
the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If 'Yes,' complete Schedule D, Part X
12a Did the organization obtain separate, independent audited financial statements for the tax year? If 'Yes,' complete
Schedule D, Parts X/ and Xll
b Was the organization included in consolidated, independent audited financial statements for the tax year?
If "Yes," and If the organization answered 'No' to line 12a, then completing Schedule D, Parts X/ and Xll is optional
13 Is the organization a school described in section 170(b)(1)(A)(i)' If 'Yes,' complete Schedule E
14a Did the organization maintain an office, employees, or agents outside of the United States?

11f

X

12a

X

12b
13

X
X

14a

X

14b

X

15

X

16

X

b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business,
investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000
or more' If "Yes," complete Schedule F, Parts / and IV

15
16
17

Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any
foreign organization? If 'Yes," complete Schedule F, Parts 11 and IV
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to
or for foreign individuals'? If 'Yes,' complete Schedule F, Parts 111 and IV
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX,
column (A), lines 6 and 11 e? If "Yes,' complete Schedule G, Part /

18

1 c and 8a? If 'Yes,' complete Schedule G, Part //

19

17

X

Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines
18

X

19

X

Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If 'Yes,'
complete Schedule G, Part 111

Form 990 (2016)

632003 11-11-16

15020926 798302 1381A

4
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 CONVENTION OF STATES ACTION

47-2245708

Page 4
!es

20a Did the organization operate one or more hospital facilities? If 'Yes,' complete Schedule H
b If 'Yes' to line 20a, did the organization attach a copy of its audited financial statements to this return?
21 Did the organization report more than $5,000 of grants or other assistance to any domestic organization or
.
domestic government on Part IX, column (A), line 19 If 'Yes,' complete Schedule IF, Parts / and //
22 Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on
Part IX, column (A), line 2' If 'Yes,' complete Schedule 1, Parts I and Ill
.
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 highest compensated employees? If 'Yes,' complete
Schedule J
24a Did the organization have a tax-exempt bond issue with an outstanding principal 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 'No', go to line 25a
b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?
c Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease
any tax-exempt bonds?
d Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year'
25a Section 501(c )(3), 501 (c)(4), and 501 (c)(29) organizations . Did the organization engage in an excess benefit
transaction with a disqualified person during the year? If 'Yes,' complete Schedule L, Part l
b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and
that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ? If 'Yes,' complete
Schedule L, Part /
26 Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any current or
former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If 'Yes,"
complete Schedule L, Part 11
27 Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial
contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member
of any of these persons" If 'Yes,' complete Schedule L, Part Ill
28 Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV
instructions for applicable filing thresholds, conditions, and exceptions)a A current or former officer, director, trustee, or key employee? If 'Yes,' complete Schedule L, Part IV
b A family member of a current or former officer, director, trustee, or key employee? If "Yes,' complete Schedule L, Part IV

c An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer,
director, trustee, or direct or indirect owner' If "Yes,' complete Schedule L, Part IV
29
30

Did the organization receive more than $25,000 in non-cash contributions? If 'Yes," complete Schedule M

32
33
34

X

X
X

X

243

X

1

24b

24c
24d
25a

X

25b

X

26

X

27

X

28a
28b

X
X

28c
29

X
X

30

X

31

X

32

X

33

X

Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation
contributions? If 'Yes," complete Schedule M

31

No

-

Did the organization liquidate, terminate, or dissolve and cease operations?

If 'Yes,' complete Schedule N, Part I
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets7lf 'Yes,' complete
Schedule N, Part 11
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 l
Was the organization related to any tax-exempt or taxable entity? If "Yes,' complete Schedule R, Part ll, Ill, or IV, and
Part V, line 1

3a

35a Did the organization have a controlled entity within the meaning of section 51 2(b)(1 3)'?
b If "Yes" to line 35a, did 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,' complete Schedule R, Part V, line 2
36 Section 501(c )(3) organizations . Did the organization make any transfers to an exempt non-chartable related organization?
If 'Yes,' complete Schedule R, Part V, line 2
37 Did the organization conduct more than 5% of its activities through an entity that is not a related organization
and that is treated as a partnership for federal income tax purposes'? If 'Yes,' complete Schedule R, Part VI
38 Did the organization complete Schedule 0 and provide explanations in Schedule 0 for Part VI, lines 11 b and 19?
Note . Al Form 990 filers are required to complete Schedule 0

X

X

38 1 X
Form 990 (2016)

632004 11-11-16

15020926 798302 1381A

5
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 47-2245708

CONVENTION OF STATES ACTION
Form 990 2016
Part V Statements Regarding Other IRS Filings and Tax Compliance

Pag e 5

Check if Schedule 0 contains a response or note to any line in this Part V
Yes
is Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable
1.
lb
b Enter the number of Forms W-2G included in line 1a Enter -0- if not applicable
c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming
(gambling) winnings to prize winners?
2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements,
filed for the calendar year ending with or within the year covered by this return
2a
b If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
3a Did the organization have unrelated business gross Income of $1,000 or more during the year?
b If "Yes," has it filed a Form 990-T for this year? If 'No,' to line 3b, provide an explanation in Schedule 0
4a At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a

No

12
0
Ic

x

0

financial account in a foreign country (such as a bank account, securities account, or other financial account)?

2b
3a
3b

X

4a

X

5a
5b
5c

X
X

b If "Yes," enter the name of the foreign country 01

See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
If "Yes," to line 5a or 5b, did the organization file Form 8886-T?
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit
any contributions that were not tax deductible as charitable contributions?
b If "Yes,' did the organization include with every solicitation an express statement that such contributions or gifts
were not tax deductible'?

5a
b
c
6a

7

a Initiation fees and capital contributions included on Part VIII, line 12

10a

b Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities

6b

X

10b

7a
7b

X

7c

X

7e
7f
7
7h
8
9a
9b

Section 501(c )( 12) organizations . Enter:

a Gross income from members or shareholders
b Gross income from other sources (Do not net amounts due or paid to other sources against

I la
11b

amounts due or received from them.)

12a Section 4947( a)(1) non - exempt charitable trusts . Is the organization filing Form 990 in lieu of Form 1041?

b If "Yes," enter the amount of tax-exempt interest received or accrued during the year
13

X

Organizations that may receive deductible contributions under section 170(c).

a Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor'
b If "Yes,' did the organization notify the donor of the value of the goods or services provided?
c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required
to file Form 8282"
- 7d
d If "Yes," indicate the number of Forms 8282 filed during the year
e Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
g If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?
h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?
8 Sponsoring organizations maintaining donor advised funds . Did a donor advised fund maintained by the
sponsoring organization have excess business holdings at any time during the year?
9 Sponsoring organizations maintaining donor advised funds.
a Did the sponsoring organization make any taxable distributions under section 4966?
b Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?
10 Section 501(c)(7) organizations . Enter:

11

6a

12a

12b

Section 501(c )( 29) qualified nonprofit health insurance issuers.

a Is the organization licensed to issue qualified health plans in more than one state?
Note . See the instructions for additional information the organization must report on Schedule 0
b Enter the amount of reserves the organization is required to maintain by the states in which the
organization is licensed to issue qualified health plans
c Enter the amount of reserves on hand

13a

13b
13c

14a Did the organization receive any payments for indoor tanning services during the tax years
b If "Yes." has it filed a Form 720 to report these payments" If 'No,' provide an explanation in Schedule 0

14a

X

14b

Form 990 (2016)
632005 11-11-16

15020926 798302 1381A

6
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 CONVENTION OF STATES ACTION
47- 2245708
Paoe6
Form 990 (2016)
Part VI Governance , Management , and Disclosure For each 'Yes' response to lines 2 through 7b below, and for a 'No • response
to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule 0 See instructions.

Check if Schedule 0 contains a response or note to any line in this Part VI

Section A. Governing Body and Management
Yes
is Enter the number of voting members of the governing body at the end of the tax year
If there are material differences in voting rights among members of the governing body, or if the governing
body delegated broad authority to an executive committee or similar committee, explain in Schedule 0.

b Enter the number of voting members included in line 1 a, above, who are independent
1b
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other
officer, director, trustee, or key employee?
3 Did the organization delegate control over management duties customarily performed by or under the direct supervision
of officers, directors, or trustees, or key employees to a management company or other person?
4 Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
5 Did the organization become aware during the year of a significant diversion of the organization's assets?
6 Did the organization have members or stockholders?
7a Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or
more members of the governing body?
b Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or
persons other than the governing body?
8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a The governing body?
b Each committee with authority to act on behalf of the governing body?
_
9 Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the
organization's marlin address's If 'Yes,' provide the names and addresses In Schedule 0

No

4

la

3

2

X

2
3
4
5
6
_

X
X
X
X

7a

X

7b

X

8a
8b

X
X
X

9

Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code)

Yes
10a Did the organization have local chapters, branches, or affiliates'?
_
b If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates,
and branches to ensure their operations are consistent with the organization's exempt purposes?

10a
10b

11a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
b Describe in Schedule 0 the process, if any, used by the organization to review this Form 990.

11a

X

12a Did the organization have a written conflict of interest policy? If 'No,' go to line 13

12a

X

b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts'?
c Did the organization regularly and consistently monitor and enforce compliance with the policy'? If 'Yes,' describe
in Schedule 0 how this was done
13

Did the organization have a written whistleblower policy')

14

Did the organization have a written document retention and destruction policy?

15

Did the process for determining compensation of the following persons include a review and approval by independent

_

persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a The organization's CEO, Executive Director, or top management official
b Other officers or key employees of the organization
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 joint venture or similar arrangement with a
taxable entity during the year?
_
b If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation
in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization's
exem pt status with res pect to such arran g ements?

17
18

19

No
X

12b

X

12c

X

13

A

14

X

15a
15b

X
X

16a

X

16b

List the states with which a copy of this Form 990 is required to be filed 10' AL, AR, AR, CA , CT, CO, FL , GA , IL , KS , KY, ME
Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (Section 501 (c)(3)s only) available
for public inspection . Indicate how you made these available . Check all that apply.
® Upon request
0 Own website
0 Another' s website
0 Other (explain in Schedule 0)
Describe in Schedule 0 whether (and if so , how) the organization made its governing documents, conflict of interest policy , and financial
statements available to the public during the tax year.

State the name , address , and telephone number of the person who possesses the organization 's books and records- ^
CLIFTON LARSON ALLEN LP - 317- 574-9100
9365 COUNSELORS ROW
200 , INDIANAPOLIS, IN
46 240-2045
SEE SCHEDULE 0 FOR FULL LIST OF STATES
632006 11 - 11-16
20

15020926 798302 1381A

Form 990 (2016)

7
2016. 04020 CONVENTION OF STATES ACTION 1381A__.1

 47-2245708
CONVENTION OF STATES ACTION
Form 990 2016
Part VII Compensation of Officers, Directors , Trustees, Key Employees, Highest Compensated
Employees, and Independent Contractors
Section A.

Check if Schedule 0 contains a response or note to any line in this Part VII
Officers, Directors , Trustees , Key Employees , and Highest Compensated Employees

Pag e 7

Q

1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization's tax year
• List all of the organization' s current officers, directors, trustees (whether individuals or organizations), regardless of amount of compensation.
Enter -0- in columns (D), (E), and (F) if no compensation was paid.

• List all of the organization' s current key employees, if any. See instructions for definition of 'key employee.'
• 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.
• 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.
• List all of the organization' s former directors or trustees that received, in the capacity as a former director or trustee of the organization,
more than $10,000 of reportable compensation from the organization and any related organizations.
List persons in the following order: individual trustees or directors; institutional trustees ; officers; key employees; highest compensated employees;
and former such persons.
= Check this box if neither the oraantzation nor any related organization comoensated any current officer, director. or trustee
(A)
(C)
(D)
(E)
(8)
Position
Reportable
Name and Title
Average
Reportable
(do not check more than one
compensation
compensation
hours per box, unless person is both an
officer and a director/trustee )
from related
week
from
organizations
the
(list any
organization
(W-2/1099-MISC)
hours for
'F2
2
(W-2/1099-MISC)
related
organizations = =
- o
below
E -Z'
r_+
E
E
line)
(1)

MARK MECKLER

CEO
(2)

1 , 0 0

ERIC O'KEEFE

KYLE STALLINGS

MICHAEL RUTHENBERG

VICE PRESIDENT/SECRETARY
(6)

X

0 .

0 .

0 .

X

0 .

0 .

0 .

X

0 .

0 .

0 .

X

0.

100,400.

23,048.

X

0.

0.

0.

1.00

DIRECTOR
(5)

18,452.

1 . 00

DIRECTOR
(4)

220,200.

TIMOTHY MURPHY

CFO

632007 11-11-16

15020926 798302 1381A

X

1.00

DIRECTOR
(3)

0.

40.00 X
TIM DUNN

(F)
Estimated
amount of
other
compensation
from the
organization
and related
organizations

1.00
40 , 00
1.00

Form 990 (2016)

2016.04020 CONVENTION OF STATES ACTION 1381A1

 CONVENTION

Form 990 (2016)
art V((

OF

STATES

ACTION

(A)
Name and title

(B)
Average
hours p er
week
(list any
hours for
related
organizations
below
line)

(C)
Position
( do not check more than one
box, unless person is both an
officer and a duector/trustee )

°

Page8

bi

(D)
Reportable
compensation
from

(E)
Re p ortable
compensation
from related

(F)
Estimated
amount of
other

the
organization
(W-2/1099-MISC)

organizations
(W-2/1099-MISC)

compensation
from the
organization
and related
organizations

z
E

°s

o

L E s€

lb Sub-total

110.

c Total from continuation sheets to Part VII, Section A
d Total add lines lb and 1c

2

47-2245708

Section A. Offirarc nirprtnrs Tructaac Kpv Fmnlnvaac nnr1 Hinhoct Cmmnnnmtnd Fmnlnvnoa (cnntrnuctrll

^

0.

320, 600.

0 •

0 •

0.

3 2 0, 6 0 0.

41,500.
0

41, 5 0 0.

Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable
com pensation from the organization 10,
Yes

3
4
5

Did the organization list any former officer, director, or trustee, key employee, or highest compensated employee on
line 1 a'? If 'Yes," complete Schedule J for such individual
For any individual listed on line 1 a, is the sum of reportable compensation and other compensation from the organization
and related organizations greater than $150,000? If "Yes, ° complete Schedule J for such individual
Did any person listed on line 1 a receive or accrue compensation from any unrelated organization or individual for services

rendered to the org anization? If 'Yes,' complete Schedule J for such person
Section B . Independent Contractors
1

X

3
4

0
No

X

5

X

Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from
the oroanization. Reoort compensation for the calendar year ending with or within the organization's tax year

(A)
Name and business address

(B)
Description of services

INTEGRAM
22695 COMMERCE CENTER CT, DULLES, VA 20166 D IRECT MAIL PRINT ING
TOM A COBURN MD INC
PO BOX 1760, MUSKOGEE, OK 74402
OVERNMENT RELATIONS
THE RICHARD NORMAN COMPANY, 113 EAST
SROW ACCOUNT
MARKET ST, SUITE 300, LEESBURG , VA 20176
ERVI CES
CREATIVE RESPONSE CONCEPTS, 2760
UBLIC RELATIONS
EISENHOWER AVE, FL 4, ALEXANDRIA, VA 22314
ERVICES

2

(C)
Compensation

300,995.
240,000.
136,05 6.
130,472.

Total number of independent contractors (including but not limited to those listed above) who received more than
$100 , 000 of com p ensation from the org anization

4
Form 990 (2016)

632008 11-11-16

15020926 798302 1381A

9
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 47- 2245708

CONVENTION OF STATES ACTION
Form 990 2016
Part VIII
Statement of Revenue
Check if Schedule 0 contains a response or note to any line in this Part VIII

Total revenue

y
y
c C
10

1 a Federated campaigns
b Membership dues

1a
lb

yQ

c Fundraising events

1c

o
S'E

d Related organizations
e Government grants (contributions)
f All other contributions, gifts, grants, and

1d
le

2=
0

similar amounts not included above

if

cL15

Pag e 9
0

Related or
exempt function
revenue

Revenue excluded
der
fro
seccttions
512 - 514

Unrelated
business
revenue

, 903 , 002

Noncash contnbuUons inciudod In itnoa to-tr $

c 0

9

V

h Total. Add lines 1 a-1 f

po.

4 ,903,002.

Business Cod
2a
b
c

c
co m

d

o
I

e

IL

f

3

F
__
All other program service revenue

Total. Add lines 2a-2f
Investment income (including dividends, interest, and

10,

other similar amounts)

^

4

Income from investment of tax-exempt bond proceeds

^

5

Royalties

^
Real

26,012.

26,012.

a Personal

6 a Gross rents
b Less. rental expenses
c Rental income or (loss)

_

d Net rental income or (loss)
7 a Gross amount from sales of

^
n Other

i Securities

assets other than inventory
b Less cost or other basis
and sales expenses
c Gain or (loss)
d Net gain or (loss)

^

8 a Gross income from fundraising events (not

including $
of
contributions reported on line 1 c). See
Part IV, line 18
b Less: direct expenses

a
b

c Net income or (loss) from fundraising events

9 a Gross income from gaming activities. See
Part IV, line 19
b Less direct expenses

^

a
b

c Net income or (loss) from gaming activities

^

10 a Gross sales of inventory, less returns
and allowances

b Less cost of goods sold

-

a

-

b

c Net income or ( loss) from sales of invento ry
Miscellaneous Revenue

B usiness Cod

11 a

b
c
d All other revenue
e Total. Add lines 11 a-11 d

12

Total revenue. See instructions.

632009 11-11-16

15020926 798302 1381A

^

^ K,929,014.

26,012. 1

0.

0.
Form 990 (2016)

10
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 CONVENTION OF STATES ACTION
Form 990 2016
Part IX Statement of Functional Expenses

47-2245708

Pa e10

Section 501(c)(3) and 501(c)(4) organizations must complete all columns All other organizations must complete column (A)

X

Check if Schedule 0 contains a response or note to any line in this Part IX
Do not Include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part ylll.

Total expenses

Program service
exp enses

Management and
general expenses

Fundraising
expenses

Grants and other assistance to domestic organizations
and domestic governments . See Part IV, line 21
Grants and other assistance to domestic
individuals . See Part IV , line 22
Grants and other assistance to foreign
organizations , foreign governments , and foreign
individuals. See Part IV, lines 15 and 16
Benefits paid to or for members

1
2
3

4
5

Compensation of current officers, directors,
trustees , and key employees

Compensation not included above, to disqualified
persons (as defined under section 4958 (f)(1)) and
persons described in section 4958 ( c)(3)(B)
Othersalanesandwages
Pension plan accruals and contributions (include
section 401(k) and 403 ( b) employer contributions)
Other employee benefits

6

7
8
9
10

Payroll taxes

11

Fees for services (non-employees).

590,299.

348,276.

118,060.

123,963.

50,224.

29,632.

10,045.

10,547.

50, 937.
60,113.
188,215.

42,262.

8,675.
6 0 ,113.

a Management

b Legal

c Accounting
d
e
f
g
12

Lobbying
Professional fundraising services. See Part IV, line 17
Investment management fees
Other . ( If line 11g amount exceeds 10% of line 25,
column ( A) amount, list line 11 g expenses on Sch 0.)
Advertising and promotion

13

Office expenses

14

Information technology

15

Royalties

16 Occupancy
17 Travel
18

1,153,532.

73 , 301.
981,182.
108,949.

26, 846.
937,535.
61,753.

9 , 598.
27,425.
25,325.

36,857.
1 6 ,222.
2 1 ,871.

16,007.
134, 879.

9,444.
104, 932.

3,202.
23,809.

3,361.
6,138.

6,659.

6,659.

Payments of travel or entertainment expenses
for any federal, state , or local public officials

19

Conferences , conventions , and meetings

20

Interest

21
22

Payments to affiliates
Depreciation , depletion, and amortization

23

Insurance

24

Other expenses . Itemize expenses not covered
above. (List miscellaneous expenses in line 24e. If line
24e amount exceeds 10% of line 25, column (A)
amount, list line 24e expenses on Schedule 0.)

a DUES & SUBSCRIPTIONS
b EVENTS
c POSTAGE & MAILING
d
e All other expenses
25 Total functional expenses . Add lines 1 through 24e
26

188,215.

1 , 15 3 , 532.

8,532.

8,532.

59,652.

35,195.

11,930.

12,527.

35,293.
31,208.
23,006.

12,547.
30,793.
18,173.

22,099.

647.
415.

3,571,989.

1, 852,2 62. '

333,646.

4,833.

1, 386,080.

Joint costs . Complete this line only if the organization
reported in column ( B) joint costs from a combined
educational campaign and fundraising solicitation.
Check here 10, = if followin g SOP 98-2 (ASC 958-720

632010 11-11-16

15020926 798302 1381A

Form 990 (2016)

11
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 CONVENTION OF STATES ACTION

47-2245708

Pagel1

Check if Schedule 0 contains a response or note to any line in this Part X

U

(A)
Beginning of year

531,615.

I
2
3

Cash - non-interest-beanng
Savings and temporary cash investments
Pledges and grants receivable, net

-

4

Accounts receivable, net

-

5

7

Loans and other receivables from current and former officers, directors,
trustees, key employees, and highest compensated employees. Complete
Part II of Schedule L
Loans and other receivables from other disqualified persons (as defined under
section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing
employers and sponsoring organizations of section 501(c)(9) voluntary
employees' beneficiary organizations (see instr). Complete Part II of Sch L
Notes and loans receivable, net

8

Inventories for sale or use

6

(B)
End of year

1

100-

4

. 0.

5

6
7
8

9 Prepaid expenses and deferred charges
10a Land, buildings, and equipment: cost or other
basis Complete Part VI of Schedule D
b Less accumulated depreciation

1,272.

-

9

16,500.

10a
10c

10b

11

Investments - publicly traded securities

12

Investments - other securities. See Part IV, line 11

12

13

Investments - program-related. See Part IV, line 11

13

14

Intangible assets

14

15

Other assets. See Part IV, line 11

16

Total assets . Add lines 1 throu g h 15 must equal line 34

17

Accounts payable and accrued expenses

18

Grants payable

19

Deferred revenue

19

20
21
22

Tax-exempt bond liabilities
Escrow or custodial account liability. Complete Part IV of Schedule D
Loans and other payables to current and former officers, directors, trustees,
key employees, highest compensated employees, and disqualified persons

20
21

Complete Part II of Schedule L

22

23
24
25

Secured mortgages and notes payable to unrelated third parties
Unsecured notes and loans payable to unrelated third parties
Other liabilities (including federal income tax, payables to related third
parties, and other liabilities not included on lines 17.24) Complete Part X of

23
24

26

Total liabilities . Add lines 17 throu g h 25

11

_

15

532,987. 16
295,587. 17

1,820,586.
226,160.

18

25

Schedule D
Organizations that follow SFAS 117 (ASC 958), check here ^
y

1,804,086.

2
3

LXJ

295,587. 26

22 6 ,1 9-0.

237,400. 27

1,594,426.

and

complete lines 27 through 29, and lines 33 and 34.

cm

27

Unrestricted net assets

m

28

Temporarily restricted net assets

29

Permanently restricted net assets

0.

28

0

29

LL

Organizations that do not follow SFAS 117 (ASC 958), check here 00-ED

o

and complete lines 30 through 34.
30

Capital stock or trust principal, or current funds

30

Q

31
32

Paid-in or capital surplus, or land, building, or equipment fund
Retained earnings, endowment, accumulated income, or other funds

31
32

Z

33

Total net assets or fund balances

2 3 7, 4 0 0. 33

34

Total liabilities and net assets/fund balances

5 3 2 , 9987. 34

1,594,426.
1,820,586.
Form 990 (2016)

632011 11-11-16

15020926 798302 1381A

12
2016.04020 CONVENTION OF STATES ACTION 1381A1

 47 -2245708

CONVENTION OF STATES ACTION
F rm99o 2016
Part XI Reconciliation of Net Assets

Pa e12

Check if Schedule 0 contains a response or note to any line in this Part XI
1

4,929,014.

2

3,571,988.

3

1,3 57,026.

Net assets or fund balances at beginning of year ( must equal Part X, line 33 , column (A)) -

4

237,400.

Net unrealized gains ( losses ) on investments

5

Donated services and use of facilities
Investment expenses
Prior period adjustments
Other changes in net assets or fund balances (explain in Schedule 0)
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33,

6
7
8
9

column B

10

1

Total revenue (must equal Part VIII, column (A), line 12)

2
3

Total expenses (must equal Part IX, column (A), line 25)
Revenue less expenses. Subtract line 2 from line 1

4
5

6
7
8
9
10

-

-

-

-

0

1,594,426.

Part XII Financial Statements and Reporting
Check if Schedule 0 contains a res ponse or note to any line in this Part XII
Yes
1
2a

b

c

3a
b

0 Other
Accounting method used to prepare the Form 990 :
Cash
® Accrual
If the organization changed its method of accounting from a prior year or checked " Other," explain in Schedule 0
Were the organization 's financial statements compiled or reviewed by an independent accountant'
If "Yes," check a box below to indicate whether the financial statements for the year were compiled or reviewed on a
separate basis , consolidated basis, or both.
0 Consolidated basis
Both consolidated and separate basis
= Separate basis
Were the organization ' s financial statements audited by an independent accountant'
If "Yes," check a box below to indicate whether the financial statements for the year were audited on a separate basis,
consolidated basis , or both
Both consolidated and separate basis
© Separate basis
= Consolidated basis
If "Yes" to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit,
review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
As a result of a federal award , was the organization required to undergo an audit or audits as set forth in the Single Audit
Act and OMB Circular A- 133?
If "Yes ," did the organization undergo the required audit or audits? If the organization did not undergo the required audit
or audits. explain why in Schedule 0 and describe any steps taken to undergo such audits

2a

X

2b

X

2c

X

3a

No

X

3b
Form 990 (2016)

632012 11-11-16

15020926 798302 1381A

13
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 SCHEDULE D

OMB No

Supplemental Financial Statements

(Form 990)

^ Complete if the organization answered "Yes" on Form 990,

Department of the Treasury
Revenue Service

Part IV , line 6,7 , 8,9, 10 , 11a, 11b, 11c, 11d, 11e, 11f , 12a, or 12b.
^ Attach to Form 990.
10- Information about Schedule D ( Form 990) and its instructions is at www. i1s.gov1form990.

1545-0047

2016
pen to Public
Open
In sp ection
to

Name of the organization
Part I

Employer identification number
CONVENTION OF STATES ACTION
47-2245708
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts .Complete if the
organization answered 'Yes' on Form 990, Part IV, line 6.
(b) Funds and other accounts
(a) Donor advised funds

Total number at end of year
Aggregate value of contributions to (during year)
Aggregate value of grants from (during year)
Aggregate value at end of year
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds
are the organization's property, subject to the organization's exclusive legal control?
6 Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only
for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring
im permissible pnvate benefit'
Part II
Conservation Easements . Complete if the organization answered 'Yes' on Form 990, Part IV, line 7
1
2
3
4
5

1

Yes

No

Yes

No

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e g , recreation or education)
Protection of natural habitat
Preservation of open space
2

Preservation of a historically important land area
Preservation of a certified historic structure

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last
Held at the End of the Tax Year
day of the tax year.
a Total number of conservation easements

_

b Total acreage restricted by conservation easements
c Number of conservation easements on a certified historic structure included in (a)

2a
2b

_

2c

d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure
listed in the National Register

2d

6

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the tax
year ^
Number of states where property subject to conservation easement is located ^
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of
violations, and enforcement of the conservation easements it holds'?
Yes
Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year

7

11111Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year

3
4
5

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(I)
and section 170(h)(4)(B)(I)?
= Yes
9 In Part All, describe how the organization reports conservation easements in its revenue and expense statement, and balance sheet, and
include, if applicable, the text of the footnote to the organization's financial statements that describes the organization's accounting for
conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures , or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

No

8

No

1a If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII,
the text of the footnote to its financial statements that describes these items.
b If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical
treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts
relating to these items:

(i) Revenue included on Form 990, Part VIII, line 1
^ $
(ii) Assets included in Form 990, Part X
_
^ $
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide
the following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

2
a

Revenue included on Form 990, Part VIII, line 1

^ $

b Assets Included in Form 990, Part X

^ $

LHA For Paperwork Reduction Act Notice , see the Instructions for Form 990.

Schedule D (Form 990) 2016

632051 08-29-16

15020926 798302 1381A

21
2016. 04020 CONVENTION OF STATES ACTION 1381A_1

 CONVENTION OF STATES ACTION
hedule D Form 990 2016
47-2245 708 Pa e 2
Part II I I Organizations Maintaining Collections of Art , Historical Treasures, or Other Similar Assets(continued)
3

Using the organization ' s acquisition , accession , and other records, check any of the following that are a sign ifi cant use of its collection items
(check all that apply):
a

El Public exhibition

d

b

0 Scholarly research

e

Loan or exchange programs
=Other

c

0 Preservation for future generations
Provide a description of the organization 's collections and explain how they further the organization 's exempt purpose in Part XIII
During the year, did the organization solicit or receive donations of art , historical treasures , or other similar assets
to be sold to raise funds rather than to be maintained as part of the organization 's collection?
Yes
L1 No
Part IV Escrow and Custodial Arrangements . Complete if the organization answered " Yes" on Form 990, Part IV, line 9, or
reported an amount on Form 990 , Part X, line 21.
4
5

la Is the organization an agent, trustee , custodian or other intermediary for contributions or other assets not included
on Form 990 , Part X?
b If "Yes ," explain the arrangement in Part XIII and complete the following table

No

Yes
Amount

c Beginning balance

d
e
f
2a
b

1c

Additions during the year
1d
Distributions during the year
le
Ending balance
if
Did the organization include an amount on Form 990 , Part X, line 21 , for escrow or custodial account liability?
If "Yes , " exp lain the arran gement in Part XIII Check here if the exp lanation has been p rovided on Part XIII

PartV

Yes

No

Endowment Funds . Complete if the organization answered 'Yes" on Form 990, Part IV, line 10

(a) Current year

( b ) Prior year

(c) Two years back

(d) Three years back

(e) Four years back

1a Beginning of year balance
b Contributions
c Net investment earnings, gains, and losses
d Grants or scholarships

e Other expenditures for facilities
and programs
f Administrative expenses
g End of year balance
2 Provide the estimated percentage of the current year end balance (line 1 g, column (a)) held asa Board designated or quasi-endowment ^
%
b Permanent endowment ^
%
c Temporarily restricted endowment ^
%
The percentages on lines 2a, 2b, and 2c should equal 100%
3a Are there endowment funds not in the possession of the organization that are held and administered for the organization
by:
(i) unrelated organizations
(ii) related organizations
b If "Yes" on line 3a(ii), are the related organizations listed as required on Schedule R"
_
4 Describe in Part XIII the intended uses of the organization's endowment funds

rlPirt VI

Yes

No

3a i
3a ii
3b

Land, Buildings , and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11 a See Form 990, Part X, line 10
Description of property
(a) Cost or other
(b) Cost or other
(c) Accumulated
basis (investment)
basis (other)
depreciation

la Land
b Buildings
c Leasehold improvements _
d Equipment
e Other
Total. Add lines 1 a throw h 1 e (Column (d) must equal Form 990, PartX, column B , line 10c

(d) Book value

0.
Schedule D (Form 990) 2016

632052 08-29-16

15020926 798302 1381A

22
2016.04020 CONVENTION OF STATES ACTION 1381A1

 CONVENTION OF STATES ACTION
Schedule D Form 990 2016
P art VII Investments - Other Securities.

47-2245708

Pa e 3

Complete if the organization answered 'Yes' on Form 990, Part IV, line 11 b. See Form 990, Part X, line 12.
(a) Description of security or category including name of sec,.rcy)
(b) Book value
(c) Method of valuation . Cost or end-of-year market value
(1) Financial derivatives

(2) Closely-held equity interests
(3) Other
A
(B)
C
(D)

G
(H)
Total. ( Col. ( b ) must e q ual Form 990, Part X, col. ( B ) line 12. ) ^

Part VIII Investments - Program Related.
Complete if the organization answered "Yes' on Form 990, Part IV, line 11 c. See Form 990, Part X, line 13
(a) Description of investment
(b) Book value
(c) Method of valuation . Cost or end-of-year market value
1

(2)
3

(4)
5
(6)
7

8
(9)
Total . ( Col. b must equal Form 990 , Part X, col. ( B ) line 13. ) ^

Part IX

2.

Other Assets.

Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the
organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII 1XI
Schedule D (Form 990) 2016

632053 08-29-16

15020926 798302 1381A

23
2016.04020 CONVENTION OF STATES ACTION 1381A1

 CONVENTION OF STATES ACTION
47- 2245708
Schedule D ( Form 990) 2016
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return.
1
2
a
b
c
d
e
3
4
a
b
c
5

Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
Total revenue, gains, and other support per audited financial statements
Amounts included on line 1 but not on Form 990, Part VIII, line 12:
Net unrealized gains (losses) on investments
Donated services and use of facilities
Recovenes of prior year grants
Other (Describe in Part XIII)
Add lines 2a through 2d
Subtract line 2e from line 1
Amounts included on Form 990, Part VIII, line 12, but not on line 1:
Investment expenses not included on Form 990, Part VIII, line 7b
Other (Describe in Part XIII.)
.,
Add lines 4a and 4b
Total revenue Add lines 3 and 4c. his must equal Form 990, Part line 12 )

Paae 4

1

4,929714-

2e
3

0.
4 ,929,01 4 .

4c
S

4 ,929,0 14.

2a
2b
2c
2d

4a
4b
0

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return.
I
2

Complete if the organization answered "Yes' on Form 990, Part IV, line 12a
Total expenses and losses per audited financial statements
Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities
b Prior year adjustments

_

2b
2c

d Other (Describe in Part XIII.)

2d

e Add lines 2a through 2d
4

3 , 5 71, T8-8.

2a
_

c Other losses

3

1

_

Subtract line 2e from line 1

Amounts included on Form 990, Part IX, line 25, but not on line 1
a Investment expenses not included on Form 990, Part VIII, line 7b

4a

b Other (Describe in Part XIII)

4b

_

c Add lines 4a and 4b
Total expenses Add lines 3 and 4c. (This must equal Form 990, Part 1. line 18)
..^ -- p p
..... . .
I . a..
5

2e

0.

3

3,571,988.

4c

0.

5

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1 a and 4, Part IV, lines lb and 2b, Part V, line 4, Part X, line 2; Part XI,
lines 2d and 4b, and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

PART X,

LINE 2:

NO AMOUNTS HAVE BEEN IDENTIFIED,

632054 08-29-16

15020926 798302 1381A

OR RECORDED,

AS UNCERTAIN TAX POSITIONS.

Schedule D (Form 990) 2016

24
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 OMB No 1545-0047

$CHEDULE G
(Form 990 or 990-EZ)

Supplemental Information Regarding Fundraising or Gaming Activities
Complete if the organization answered 'Yes' on Form 990, Part IV, line 17, 18, or 19, or if the

^O

organization entered more than $15,000 on Form 990-EZ, line 6a.
Department of the Treasury
Internal Revenue Service

Open to Public
Inspection

^ Attach to Form 990 or Form 990-E7.
_r._... --- .. -_ .,.,,. __ ,,.,,. .. _.... __ :_ ...www it nnvlfnm,gcn

^

Name of the organization

47-2245708

C ONVENTION OF STATES ACTION
art
1

Fundraising Activities . Complete if the organization answered "Yes" on Form 990, Part IV, line 17 Form 990-EZ filers are not
required to complete this part.

Indicate whether the organization raised funds through any of the following activities . Check all that apply.
e 0 Solicitation of non - government grants

a ® Mail solicitations

® Internet and email solicitations
Solicitation of government grants
f
® Phone solicitations
g
Special fundraising events
® In-person solicitations
Did the organization have a written or oral agreement with any individual (including officers , directors , trustees, or
® Yes
key employees listed in Form 990 , Part VII) or entity in connection with professional fundraising services?
b If "Yes ,' list the 10 highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is to be
compensated at least $5 ,000 by the organization.

b
c
d
2a

(i) Name and address of individual
or entity (fundraiser)

(ii) Activity

(iii) Did
tun raiser
have custo
or control of

(v) Amount paid
(iv) Gross receipts to (or retained by)
fundraiser
from activity

contributions?

THE RICHARD NORMAN COMPANY -

113 E MARKET ST SUITE 300 ,
ACTIVE ENGAGEMENT MARKET ST SUITE

113

-

JUANITA AVE

AZ

MESA ,

(vi) Amount paid
to (or retained by)
etain d
organization

No

DIRECT MAIL

X

INTERNET & EMAIL

X

1 1 792,048.

1,073,259.

718 789.

E

300,

MDS COMMUNICATIONS

Yes

listed in col. (i)

No

75

,

891.

73

,

273.

2

,

618.

545 W
85210

Total

HONE

X

^

7 , 000.

1 , 874 , 939. 1

7,000.

0.

1,153,532.

721,407.

3 List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from registration
or licensing.

AL,AK,AZ,AR,CA,CO,CT,FL,GA,HI,IL,KS,KY,LA,ME,MA,MI,MN,MS,MO,NH,NJ,NM,NY,NC
ND,OH,OK,OR,PA,RI,SC,TN,UT,VA,WA,WV,WI

LHA For Paperwork Reduction Act Notice , see the Instructions for Form 990 or 990- EZ.
SEE PART IV FOR CONTINUATIONS

Schedule G (Form 990 or 990- EZ) 2016

632081 09-12-16

15020926 798302 1381A

25
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 47-2245708 Pa e 2
Schedule G Form 990 or 990
2016 CONVENTION OF STATES ACTION
Part
F un d raising ventS . Complete if the organization answered 'Yes' on Form 990, Part IV, line 18, or reported more than $15,000
of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.
(b) Event #2
(c) Other events
(a) Event #1
(d) Total events
(add col. (a) through
col. (c))
(total number)
(event type)
(event type)
m
M

1

Gross receipts

2

Less: Contributions

3

Gross income (line 1 minus line 21

4

Cash prizes

5

Noncash prizes

6

Rent/facility costs

7

Food and beverages

8
9

Entertainment
Other direct expenses

Co

a
a
x

w

10 Direct expense summary. Add lines 4 through 9 in column (d)

^
11 Net income summa ry . Subtract line 10 from line 3 , column
^
P art III I G aming . Complete if the organization answered "Yes" on Form 990, Part IV, line 19, or reported more than
$15,000 on Form 990-EZ, line 6a.

(b) Pull tabsfinstant
bingo/progressive bingo

(a) Bingo

(d) Total gaming (add
col (a) through col. (c))

(c) Other gaming

]

2

Cash prizes

3

Noncash prizes

4

Rent/facility costs

5

Other direct expenses

6

Volunteer labor

7

Direct expense summary Add lines 2 through 5 in column (d)

N

C

a
w
U

9

L-J Yes
No

%

Yes
No

% L-J Yes
No

%

^

Enter the state(s) in which the organization conducts gaming activities
a Is the organization licensed to conduct gaming activities in each of these states?

Yes

No

Yes

L-J No

b If "No," explain.

10a Were any of the organization's gaming licenses revoked, suspended, or terminated during the tax year?
b If "Yes," explain:

632082 09-12-16

15020926 798302 1381A

Schedule G (Form 990 or 990-EZ) 2016

26
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 Schedule G Form 990 or 990
2016 CONVENTION OF STATES ACTION
11 Does the organization conduct gaming activities with nonmembers'
12 Is the organization a grantor, beneficiary or trustee of a trust, or a member of a partnership or other entity formed
to administer charitable gaming?
13 Indicate the percentage of gaming activity conducted in:

14

47-2245708
Yes

Pa e 3
No

0 Yes

0 No

a The organization ' s facility

13a

%

b An outside facility

13b

%

Enter the name and address of the person who prepares the organization ' s gaming/special events books and records.

Name ^
Address ^
15a Does the organization have a contract with a third party from whom the organization receives gaming revenue?
b If "Yes," enter the amount of gaming revenue received by the organization ^ $
of gaming revenue retained by the third party ^ $
c If "Yes," enter name and address of the third party:

0 Yes

0 No

0 Yes

= No

and the amount

Name ^
Address ^
16

Gaming manager information
Name ^

Gaming manager compensation ^ $
Description of services provided ^ _

0 Director/officer
17

0 Independent contractor

= Employee

Mandatory distributions:
a Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license's
b Enter the amount of distributions required under state law to be distributed to other exempt organizations or spent in the
organization's own exem pt activities durin g the tax year 00 $

Part IV

Supplemental Information . Provide the explanations required by Part I, line 2b, columns (iii) and (v); and Part III, lines 9, 9b, 10b, 15b,
15c, 16, and 17b, as applicable Also provide any additional information See instructions

SCHEDULE G,

PART I,

LINE 2B,

THE RICHARD NORMAN COMPANY

(I)

NAME OF FUNDRAISER:

(I)

ADDRESS OF FUNDRAISER:

(I)

NAME OF FUNDRAISER:

(I)

ADDRESS OF FUNDRAISER :

632083 09 - 12-16

15020926 798302 1381A

LIST OF TEN HIGHEST PAID FUNDRAISERS:

113 E MARKET ST SUITE

300,

LEESBURG,

VA

20176

300 ,

LEESBURG ,

VA

20176

ACTIVE ENGAGEMENT
113 E MARKET ST SUITE

Schedule G (Form 990 or 990 - EZ) 2016

27
2016. 04020 CONVENTION OF STATES ACTION 1381A__1

 CONVENTION OF
Schedule G Form 990 or 990- EZ)
Part IV Supplemental Information (continued)

STATES ACTION

47-2245708

Pa e 4

Schedule G (Form 990 or 990-EZ)
632084

04-01-16

15020926 798302 1381A

28
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 Compensation Information

SCHEDULE J
(Form 990)
Department of the Treasury
Internal Revenue Service
Name of the organization

Part I

OMB No

For certain Officers, Directors, Trustees, Key Employees , and Highest

1545-0047

20

Compensated Employees
^ Complete if the organization answered "Yes° on Form 990, Part IV, line 23.
Open to Public
1111' Attach to Form 990.
Inspection
No- Information about Schedule J ( Form 990) and its instructions is at www. Irs.gov/form990.
Employer identification number

CONVENTION OF STATES ACTION
Questions Regarding Compensation

47-2245708

is Check the appropriate box(es) if the organization provided any of the following to or for a person listed on Form 990,
Part VII , Section A, line 1 a . Complete Part III to provide any relevant information regarding these items
First-class or charter travel
Housing allowance or residence for personal use
Travel for companions
Payments for business use of personal residence
Tax indemnification and gross-up payments
Health or social club dues or initiation fees
Discretionary spending account
Personal services (such as , maid, chauffeur, chef)
b If any of the boxes on line la are checked, did the organization follow a written policy regarding payment or
reimbursement or provision of all of the expenses described above' If "No," complete Part III to explain
2 Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all directors,
trustees, and officers, including the CEO/Executive Director, regarding the items checked on line 1 a?
3

Indicate which , if any , of the following the filing organization used to establish the compensation of the organization's
CEO/Executive Director . Check all that apply Do not check any boxes for methods used by a related organization to
establish compensation of the CEO/Executive Director , but explain in Part III.

EJ Compensation committee
0 Independent compensation consultant
Form 990 of other organizations

E:J Written employment contract
EJ Compensation survey or study
= Approval by the board or compensation committee

4

During the year, did any person listed on Form 990, Part VII, Section A, line 1 a, with respect to the filing
organization or a related organization:
a Receive a severance payment or change-of-control payment?
b Participate in, or receive payment from, a supplemental nonquallfled retirement plan?
c Participate in, or receive payment from, an equity-based compensation arrangement'?
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part Ill

4a
4b
4c

X
X

5a
5b

X
X

6a
6b

X
X

7

X

8

X

Only section 501(c)( 3), 501 ( c)(4), and 501(c)(29) organizations must complete lines 5-9.

5

For persons listed on Form 990, Part VII, Section A, line 1 a, did the organization pay or accrue any compensation
contingent on the revenues of:

a The organization"
b Any related organization?
If "Yes" on line 5a or 5b, describe in Part Ill.
6 For persons listed on Form 990, Part VII, Section A, line 1 a, did the organization pay or accrue any compensation

-

contingent on the net earnings of:

a The organization?
b Any related organization?
If "Yes' on line 6a or 6b, describe in Part III.
7 For persons listed on Form 990, Part VII, Section A, line 1 a, did the organization provide any nonfixed payments
not described on lines 5 and 69 If "Yes," describe in Part Ill
8 Were any amounts reported on Form 990, Part VII, paid or accrued pursuant to a contract that was subject to the
initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe in Part III
9 If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in
Regulatio ns section 53 4958.6(c)'
LHA For Paperwork Reduction Act Notice , see the Instructions for Form 990.

-

9
_
Schedule J (Form 990) 2016

632111 09-09-16

15020926 798302 1381A

29
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 CONVENTION OF STATES ACTION
47-2245708
Schedule J Form990 2016
Pag e 2
Part II Officer,,, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies If additions) apace Is needed
For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (I) and from related organizations, described in the instructions, on row (i)
Do not list any individuals that aren't listed on Form 990, Part VII
Note: The sum of columns (B)()-(ii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1 a, applicable column (D) and (E) amounts for that individual
( B) Breakdown of W 2 and/or 1099 MISC compensation
(i) Base
compensation

(Al Name and Title

(1) MARK )ECKLER

(,)

CEO

u

0 .

( ii) Bonus &
incentive
compensation

(iii) Other
reportable
compensation

0.

(C) Retirement and
other d e f er r e d
compensation

(D ) Nontaxable
benefi t s

0 .

0 .

0.

IJ -

0.

18,452.

(E) Total of columns
( B)()-(D)

0

238,652.

(F) Compensation
in column (B)
reported as deferred
on poor Form 990

0 .

0.

(1)

60
(I)

u
(i)

(i)

(I)
(i)

(I)
(i)
li)
(I)
(il
(i)
U)
l0
(i)
Schedule J (Form 990) 2016
632112 09 -09-16

30

 CONVENTION OF
ScheduleJ Form990 2018
Pert III Supplemental Information

STATES

47-2245708

ACTION

Pag e 3

Provide the Information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5s. 5b, 8a, Bb , 7, and 8, and for Part 11 Also complete this part for any additional Information

Schedule J (Form 990) 2016
632113 09 -09-16

31

 OMB No 1545-0D47

SCHEDULE 0

Supplemental Information to Form 990 or 990- EZ

(Form 990 or 990-EZ )

Complete to provide information for responses to specific questions on
2016
Form 990 or 990-EZ or to provide any additional information.
^ Attach to Form 990 or 990- E7Open to Public
Ins p ection
and its instructions is www. lr's. ov/forrn990.
hedule
orm 990 or 99
Informati o n abo

Department of the Treasury
internal Revenue Service

Employer identification number
47-2245708

Name of the organization
CONVENTION OF

FORM 990,

PART VI,

SECTION A,

STATES

ACTION

LINE 3:

CONTRACT WITH CITIZENS FOR SELF GOVERNANCE FOR PERSONNEL.

FORM 990,

PART VI,

SECTION B, LINE 11B:

THE RETURN IS PROVIDED TO EACH BOARD MEMBER PRIOR TO FILING.

FORM 990,

PART VI,

SECTION B,

LINE 12C:

LEGAL COUNSEL REVIEWS OUTGOING ORGANIZATIONAL PAYMENTS AND ROUTINELY
MONITORS FOR POSSIBLE CONFLICTS

OF INTEREST.

ALL MEMBERS OF THE BOARD OF

DIRECTORS ARE REQUIRED TO DISCLOSE ANY POSSIBLE CONFLICTS OF INTEREST AT
ANY OFFICER OR DIRECTOR WHO FAILS

THE ORGANIZATION'S ANNUAL BOARD MEETING.

TO PROPERLY REPORT A CONFLICT OF INTEREST IS SUBJECT TO SANCTION BY THE
BOARD.

FORM 990,

PART VI,

LINE 17,

LIST OF STATES RECEIVING COPY OF FORM 990:

AL,AK,AR,CA,CT,CO,FL,GA,IL,KS,KY,ME,MA,MI,MN,MS,NH,NJ,NM,NY,NC,ND,OH,OK,OR
PA,RI,SC,TN,UT,VA,WV,WI,AZ,HI,LA,MO,WA

FORM 990,

PART VI,

SECTION C,

LINE

19:

THE ORGANIZATION'S GOVERNING DOCUMENTS,

CONFLICT OF INTEREST POLICY,

AND

FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC ON REQUEST.

FORM 990,

PART IX,

LINE 18

IDAHO REPRESENTATIVE JAMES HOLTZCLAW $1987.70
IDAHO REPRESENTATIVE THOMAS LOERTSCHER $1450.20
IDAHO REPRESENTATIVE ERIC REDMAN $2267.20
LHA For Paperwork Reduction Act Notice , see the Instructions for Form 990 or 990- EZ.

Schedule 0 (Form 990 or 990 -EZ) (2016)

632211 08-25-16

15020926 798302 1381A

32
2016.04020 CONVENTION OF STATES ACTION 1381A_1

 hedule 0 ( Form 990 or 994

Pa g e 2

(2016)

Name of the organization

Employer identification number
CONVENTION

OF

STATES

ACTION

47-2245708

SCHEDULE R
SCHEDULE R,
STATES

PART II

(A):

FULL NAME - JOHN HANCOCK COMMITTEE FOR THE

(DBA CITIZENS FOR SELF GOVERNANCE)

632212 08-25 - 16

15020926 798302 1381A

Schedule 0 (Form 990 or 990 - EZ) (2016)

33
2016.04020 CONVENTION OF STATES ACTION 1381A1

 SCHEDULER
(Form 990)

Related Organizations and Unrelated Partnerships
^ Complete If the organization answered "Yes" on Form 990, Part IV, line 33 , 34, 35b, 38, or 37.

2016

IN- Attach to Form 990.
1

in 1

Open to Public
Inspection

Information about Schedule R ( Form 990) and Its Instructions Is at www lr3. gov/fbrm990

. sws

Employer Identification number
47-2245708

Name of the organization
CONVENTION
Part I

OF

STATES

Identification of Disregarded Entities . Complete if the organization answered *Yes* on Form 990, Part IV, line 33
(a)
Name, address, and EIN (if applicable)
of disregarded entity

P

if
-

(b)
Primary activity

(c)
Legal domicile (state or
foreign country)

(d)
Total income

(e)
End-of year assets

(f)
Direct controlling
entity

Identification of Related Tax-Exempt Organizations . Complete if the organization answered 'Yes' on Form 990, Part IV, line 34 because it had one or more related tax exempt
organizations during the tax year
(a)
Name, address, and EIN
of related organization

JOHN HANCOCK COMMITTEE FOR THE STATES
SCHEDULE 0)
900 ,

ACTION

-

27-1657203

AUSTIN, TX

78701

(b)
Primary activity

(c)
Legal domicile (state or
foreign country)

(d)
Exempt Code
section

(e)
Public charity
status (d section
501(c)(3))

(f)
Direct controlling
entity

(6q^
oontra tt31
na7
Yes

No

(SEE

106 E 6TH ST,

STE.
HABITABLE ORGANIZATION

ERAS

01(C)(3)

ERAS

01(C)(4)

L INE 7

X

CSG ACTION - 27-4648506
106 E 6TH ST,
AUSTIN ,

TX

STE.

78701

900
VOCACY

Schedule R (Form 990) 2018

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
632161 09-06-16

LHA

X

34

 Schedule R (Form 990) 2016
Pert III

CONVENTION

(a)
Name, address, and EIN
of related organization

Part IV

OF

STATES

47-2245708

ACTION

Paget

Identification of Related Organizations Taxable as a Partnership Complete if the organization answered 'Yes' on Form 990, Part IV, line 34 because it had one or more related
organizations treated as a partnership during the tax year
(b)
Primary activity

(c)
L 1.
l,r v o
ro„g
-try)

(d)
Direct controlling
entity

(a)
Predominant income
(related, unrelated,
excluded from tax
sections 512-514)

(f)
Share of total
income

(g)
Share of
end-of year
assets

(h )
e,umwmon n
^raaoanst

Yes

No

U)
(1)
(k)
ercentage
Code V UBI
d
amount in box fn°"°P"9 ownership
20 of Schedule '0"1°'
K 1 (Form 1065)
No

Identification of Related Organizations Taxable as a Corporation or Trust . Complete if the organization answered 'Yes' on Form 990, Part IV, line 34 because it had one or more related
organizations treated as a corporation or trust during the tax year
(a)
Name, address, and EIN
of related organization

(b)
Primary activity

(c)
Ley. dom,ai.
(.Mt.

(d)
Direct controlling
entity

(e)
Type of entity
(C corp, S corp,
or t rus t )

(f)
Share of total
income

(g)
Share of
end of-year
asse t s

(h)
ercentage
ownership

(I)
5,rm1131
CO"^ry7°
Yes

532152 as -ax-16

3

No

Schedule R (Form 990) 2016

 Schedule R (Form 990) 2016
Part V

CONVENTION OF

STATES

ACTION

47-2245708

Page3

Transactions With Related Organizations . Complete if the organization answered 'Yes' on Form 990, Part IV, line 34, 35b, or 36.

Note: Complete line 1 if any entity is fisted in Parts II, III, or IV of this schedule
1 During the tax year, did the organization engage in any of the following transactions with one or more related organizations listed in Parts II IV?
a

Receipt of (i) interest, (ii) annuities, (w) royalties, or (iv) rent from a controlled entity

b
c
d
e

Gift, grant, or capital contribution to related organization(s)
Gift, grant, or capital contribution from related organization(s)
Loans or ban guarantees to or for related organization(s)
Loans or loan guarantees by related organization(s)

f
g
h
i
j

Dividends from related organization(s)
Sale of assets to related organization(s)
Purchase of assets from related organization(s)
Exchange of assets with related organization(s)
Lease of facilities, equipment, or other assets to related organization(s)

k
I
m
n
o

Lease of facilities, equipment, or other assets from related organization(s)
Performance of services or membership or fundraising solicitations for related organization(s)
Performance of services or membership or fundraising solicitations by related organization(s)
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
Sharing of paid employees with related organization(s)

Yes

X

X
X

r
1bb

X
X
X
X

1
1h

X
X
X

11
1
1k
11
tm

X
X
X
X

to
10

p Reimbursement paid to related organization(s) for expenses
q Reimbursement paid by related organization(s) for expenses

1
1

r Other transfer of cash or property to related organization(s)
a Other transfer of cash or p ro p e rty from related o rg anization ( s)
2 If the answer to any of the above is 'Yes,' see the instructions for information on who must complete this line, includinq covered relationships and transaction thresholds
(a)
Name of related organization

No

(b)
Transaction
type (a-s)

(c)
Amount involved

1r
Is

X
X
X
X
X

(d)
Method of determining amount involved

( 1 ) CITIZENS FOR SELF GOVERNANCE

P

1,371,865.

CTUAL AMOUNT INVOICED

[2) CITIZENS FOR SELF GOVERNANCE

H

217,483.

CTUAL AMOUNT INVOICED

(3) CITIZENS FOR SELF GOVERNANCE

K

6,500.

CTUAL AMOUNT INVOICED

4

( )

5
( 6)

632163 as-oo-ia

36

Schedule R (Form 990) 2016

 Schedule R ( Form 99012018
Pert VI

CONVENTION

OF

STATES

47-2245708

ACTION

Pege4

Unrelated Organizations Taxable as a Partnership . Complete if the organization answered 'Yes' on Form 990, Part IV , line 37

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue)
that was not a related organization See instructions reqardino exclusion for certain investment partnerships
(a)
Name, address , and EIN
of entity

(b)
Primary activity

( a)
(d)
(c)
Predominant income
Legal domicile
related, unrelated,
507(r)(31
(state or foreign
excluded from tax under -, s
country)
sections 512-514)
as No

(0
Share of
total
income

(g)
Share of
end-of year
assets

(k)
(h)
(1)
U)
mmmoorCode V-UBI
Percentage
mount in box 20 n 909 ownership
Warn
arn
ro
of Schedule K-1
a^ No
(Form 1065)
No

Schedule R (Form 990) 2016
u32164 ce -oe-,s

37

 CONVENTION OF STATES ACTION
Schedule R Form 990 2016
P art vil Supplemental Information.
Provide additional information for responses to questions on Schedule R. See instructions

632165 09-06-16

15020926 798302 1381A

47-2245708

Pa e 5

Schedule R (Form 990) 2016

38
2016.04020 CONVENTION OF STATES ACTION 1381A__1