Form Department of Internal Revenue Service PUBLIC DISCLOSURE COPY benefit trust or private foundation) the Treasury Return of flrganizatton Exempt From income Tax Under section 501(c), 527, or of the internal Revenue Code (except black lung The organization may have to use a copy of this return to satisfy state reporting requirements. Appiication pending OMB No. 1545-0047 Name and address of principal otfioer: STEPHEN HOURIGAN ONE NORTH AVE, ININANAPOLIS, 46204 H(b} Are ali affiliates include A For the 2011 calendar year, -or tax year beginning 2011, and ending check if appiicame; Name of organization ELEVATE VENTURES INC. 13 Em13|0Vel'idEUR|3miC3ti0fl number Addresg change Doing Business As 274118692 Name change Number and street {or PO. box it mat! is not delivered to street address} Fioornrsuite Telephone number mitiai return ONE NORTH CAPITOL AVE 900 Terminated City or town, state or country, and 4 [3 Amended re;-Um IN 45204 Gross receipts 1,659,184 El H{a) is this a group return for 1: Yes N0 d? i:iYes No 1 Tax-exempt status: 501(c)(3) Cl 501(c) )4 (insert no.) [3 4g47(a)(1} or 527 If attach a list. (see instructions} Website: 18> H(c} Group exemption number Form of organization: Corporation I:i Trust Association Other 11- i Year of formation: 2010 I State of Iegai domicile: iN Summary Briefly describe the organizations mission or most significant activities: THE PRMARY PURPOSE IS TO Signature Block 1 (D DEVELOPMENT IN THE STATE av ms DEVELOPMENT 2 OF EENTREPRENEURS AND EMERGING COMPANIES iN SUPPORT OF THE ECONOMY AND ITS CREATION AND 2 Check this box 91:] if the organization discontinued its operations or disposed of more than 25% of its net assets. 3 3 Number of voting members of the governing body (Part VI, line 1aNumber of independent voting members of the governing body (Part VI, line 1b) 4 6 5 Total number of individuals employed in caiendar year 2011 (Part V, line 2a) 5 12 6 Total number of volunteers (estimate if necessaryTotai unreiated business revenue from Part Vlii, column (C), line 12 7a 0 Net unrelated business taxable income from Form 990-T, 'line 34 . . . Yb 0 Prior Year Current Year 8 Contributions and grants (Part line 1h) . 0 225,000 9 Program service revenue (Part Vili, tine 2g) . . 0 1,443,766 3 10 Investment income (Part Vill, column (A), lines Other revenue (Part Vlli, column (A), lines 5, 6d, 8c, 90, 10cTotal revenuemadd lines 8 through 11 (must equal Part column (A), line 12) 0 1,669,184 13 Grants and simiiar amounts paid (Part iX, column (A), lines 1--3) . 0 14 Benefits paid to or for members (Part IX, column (A), line Saiaries, other compensation, empioyee benefits (Part IX, column (A), lines 5-10} 0 723,893 9 16a Protessionai fundraising fees (Part IX, column (A), line Totai fundraising expenses (Part iX, coiumn (D), tine 25) 101,36? 1? Other expenses (Part IX, coiumn (A), tines 11a~11d, 11f~24e) . 0 191172 18 Total expenses. Add tines 13~17' (must equal Part IX, column (A), line 25) 0 921,065 19 Revenue iess expenses. Subtract time 18 from line 12 0 ?48.119 Beginning of Current Year End of Year 20 Total assets (Part X, line 18) 0 969,241 512% 21 Totai liabilities (Part X, line 26221,122 22 Net assets or fund batances. Subtract line 21 from line 20 0 748,119 Under penalties of perjury, I declare that i have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true. correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge. Sign Signature of officer lmate Here HOURIGAN, PRESIDENT AND CEO Type or print name and title . Print/Type preparer's.narne Preparers stgnatu Date PTIN Eg?iarer WOODHULL 1 1/15/2012 P01305288 use only FMS name bv caowrs HORWATH LLP ll Firm's an 350921680 Finn's address 3- 3815 RIVER CROSSING PARKWAY, 300, IN 46240-C Phone no' (317)559-8989 May the IRS discuss this return with the preparer shown above? (see instructions) Yes E) No For Paperwork Reduction Act Notice, see the separate instructions. 1111412012 6:33:38 PM Cat. No. 11282)' Form 990 (2011) Form 990 (2011) Page 2 Statement of Program Service Accomplishments Check if Schedule 0 contains a response to any question in this Part 1 Briefly describe the organizatiorfs mission: 2 Did the organization undertake any significant program services during the year which were not iisted on the prior Form 990 yes 13:] No if "Yes," describe these new services on Scheduie O. 3 Did the organization cease conducting, or make significant changes in how it conducts, any program . . . . . . . . . . Eyes No If "Yes," describe these changes on Schedule 0. 4 Describe the organization's program service accomplishments for each of its three iargest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to Others, the total expenses, and revenue, if any, for each program service reported. 4a (Code: (Expenses iseiudine grants of (Revenue THE DEVELOPMENT CORPORAWON THE PRIMARY - TO NURTURE AND EMERGING AND HIGH-POTENTIAL ausin?sses INTO COMPANIES. THIS is av PROVIDING AT NO COST _sui.=POaT AND ROBUST ADVISORY CONNECT REs_o_u TO THE 9.03 FOR 41) (Code (Expenses including grants of (Revenue EB 4c (Code: (Expenses inciuding grants of (Revenue 4d Other program services (Describe in Schedule 0.) (Expenses 0 including grants of 0 (Revenue 0 4e Totai program service expenses 609,225 Form 990 (2011) 6:33:38 PM 2 Form 990 (2011) Page 3 Checkiist of Required Schedules Yes No 1 is the organization described in section 501(c)(3) or [other than a private foundation)? if "Yes," completeScheduieA. 1 2 is the organization required to complete Schedule B, Scheduie of Contributors (see instructions)? . . . 2 3 Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for pubiic office? if "Yes," complete Scheduie C, Partl . . . . . . . . . . . . . . 3 4 Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 50101) election in effect during the tax year? ll "Yes, complete Schedule C, Part 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? lf "Yes, complete Schedule C, 5 6 Did the organization maintain any donor advised funds or any simiiar 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, PartDid the organization receive or hold a conservation easement, inciuding easements to preserve open space, the environment, historic land areas, or historic structures? lf "Yes," complete Schedule D, Part ll . . . 7 8 Did the organization maintain coilections of works of art, historicai treasures, or other simiiar assets? it "Yes," completeScheduieD,F'artlli . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9 Did the organization report an amount in Part X, tine 21; serve as a custodian tor amounts not listed in Part or provide credit counseling, debt management, credit repair, or debt negotiation services? if "Yes," complete Schedule D, Part lV 9 10 Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or duasi--endowments? if "Yes, complete Schedule D, Part 11 If the organization's answer to any of the following questions is "Yes," then complete Scheduie D, Parts Vi, Vii, Vlii, IX, or as applicable. 21 Did the organization report an amount for iand, buiidings, and equipment in Part X, iine 10? ll' "Yes, completeScheduleD,Parti/113 Did the organization report an amount for iitvestmentsmother securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? it "Yes, complete Schedule D, Part . . . . . . . . 1-it, Did the organization report an amount for reiated in Part X, line 13 that is 5% or more of its totai assets reported in Part X, line 16? if "Yes, complete Scheduie D, Part '-/ill . . . . . . . . 110 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, iine 16? if "Yes," complete Schedule D, PartlX 11d Did the organization report an amount for other in Part X, line 25? if "Yes, complete Schedule D, Part 'He Did the organizations separate or consolidated financiai statements for the tax year include a footnote that addresses the organization's for uncertain tax positions under FIN 48 (A80 if "Yes, complete Schedule D, Part . 11f 12 21 Did the organization obtain separate, independent audited financiai statements for the tax year? if "Yes," complete . . . . . . . . . . . . . . . . . . . . . . . . . 123 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 Xi, Xll, and is optional . . . . . -1gb 13 is the organization a school described in section lf "Yes," complete Scheduie . . . . 13 14 a Did the organization maintain an office, employees, or agents outside of the United States? . . . . . 14a 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? lf "Yes," compiete Schedule F, Parts and ii/. . . . . 14;; v' 15 Did the organization report on Part iX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? ll "Yes, complete Schedule F, Parts ll and . . 15 16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? if "Yes," complete Schedule F, Parts ill and iv . . . . 15 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 11e? if "Yes, complete Schedule G, Part (see instructionsDid the organization report more than $15,000 total of fundraising event gross income and contributions on Part vm, lines 1c and 8a? it "Yes," cornpiete Schedule (3, Part Did the organization report more than $15,000 of gross income from gaming activities on Part tine 9a? if "Yes," compiete Schedule G, Part . . . . . . . . . . . . . . . . 19 20 3 Did the organization operate one or more hospital facilities? ll' "Yes, complete Schedule . . . . . . 203 If to line 20a, did the organization attach a copy of its audited financial statements to this return? . 20b Form 990{2011) 6:33:38 PM 3 Form 990 (2011Checklist of Required Schedules (continued) Page 4 Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line i? ll' "Yes," complete Schedule l, Parts and ll . Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part iX, column (A), line 2? ll "Yes," complete Schedule l, Parts and . . . . . . . . Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organizations current and former officers, directors, trustees, key employees, and highest compensated employees? ll "Yes," complete Schedule . 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? ll' "Yes," answer lines 24b through 24d and complete Schedule K. lf "No, go to line 25 . . Did the organization invest any proceeds of tax--exempt bonds beyond a temporary period exception? . Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax--exempt bondsDid the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year? . Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? lf "Yes, complete Schedule L, Part 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 organizations prior Forms 990 loan to or'by a" current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization's tax year? ll "Yes, complete Schedule L, Pan' ll . 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? ll "Yes," complete Schedule L, Part . . . . . . . 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 current or former officer, director, trustee, or key employee? ll' "Yes," complete Schedule L, Part lV A family member of a current or former officer, director, trustee, or key employee? ll "Yes," complete 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? ll "Yes, complete Schedule L, Part ll/ . Did the organization receive more than $25,000 in non--cash contributions? ll "Yes, complete Schedule Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? li' "Yes," complete Schedule . . . . . . . . . . . Did the organization liquidate, terminate, or dissolve and cease operations? ll' "Yes," complete Schedule N, Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? lf "Yes," com,oleteScheduleN,Partll . . . . . . . . . . . . . . . . . . . . . . . . .. Did the organization own 'i 00% of an entity disregarded as separate from the organization under Regulations sections and 30i.7701--3? ll "Yes," complete Schedule H, Partl . . . . . . . . . . Was the organization related to any tax--exempt or taxable entity? ll "Yes," complete Schedule Fl, Parts ll, Did the organization have a controlled entity within the meaning of section . . . . . . . Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section ll "Yes," complete Schedule Part V, line Section 501(c)(3) organizations. Did the organization make any transfers to an exempt nomcharltable related organization? ll "Yes," complete Schedule H, Part V, line 2 . 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? ll "Yes," complete Schedule H, Did the organization complete Schedule 0 and provide explanations in Schedule 0 for Part Vi, lines it and 19? Note. All Form 990 filers are required to complete Schedule 2413 24c 24d 253 25b '1'Il14l2012 6:33:38 PM 4 Form 990 (2011) Form 990 (2011) Page 5 Statements Regarding Other IRS and Tax Compliance Partv . . . . . . . . . . . . . . Yes No 'la Enter the number reported invi3ox 3 of Form 1096. Enter -0- if not applicable . . . . 'is Enter the number of Forms W--2G included in line ta. Enter -0- if not applicable . . . . 1b Did the organization compiy with backup withhoiding rules for reportabie payments to vendors and reportable gaming (gambling) winnings to prize winnersEnter 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 1 If at least one is reported on line 2a, did the organization file ali required federal empioyment tax returns? Note. It the sum of iines ta and 2a is greater than 250, you may be required to e~fr'ie (see instructions) 38 Did the organization have unrelated business gross income of $1,000 or more during the year? . If "Yes," has it filed a Form 990--T for this year? if provide an explanation in Scheduie . . . . 3b 4a At any time during the caiendar year, did the organization have an interest in, or a signature or other authority over, a financiat account in a foreign country (such as a bank account, securities account, or other financial is it "Yes," enter the name of the foreign country: See instructions for filing requirements for Form TD Report of Foreign Bank and Financial Accounts. 5a 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 sheiter transaction? Sb 1/ If "Yes" to iine 5a or Sb, did the organization fiie Form . . . . . . . . . . . . . . . 5c Ba Does the organization have annual gross receipts that are normaiiy greater than $100,000, and did the organization solicit any contributions that were not tax deductible"Yes," did the organization inciude with every solicitation an express statement that such contributions or gifts were not tax deductibieOrganizations that may receive deductible contributions under section 170(0). 8 Did the organization receive a payment in excess of $75 made partiy as a contribution and parity for goods and services provided to the payor"Yes," did the organization notify the donor of the vaiue of the goods or services provided? . . . . . Did the organization sell, exchange, or otherwise dispose of tangibie personai property for which [Yd] If "Yes," indicate the number of Forms 8282 flied during the year . . . . . . . . Did the organization receive any funds, directly or indirectiy, to pay premiums on a personal benefit contract? Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? . if the organization received a contribution of quaiified inteilectuai property, did the organization file Form 8899 as required? If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form t098~C? 8 Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year? . . 9 Sponsoring organizations maintaining donor advised funds. a Did the organization make any taxabie distributions under section 4966? . . Did the organization make a distribution to a donor, donor advisor, or reiated person? 10 Section 501(c)(7) organizations. Enter: a initiation fees and capital contributions included on Part iine . . . . . . . 10.3 Gross receipts, inciuded on Form 990, Part Vili, iine 12, for public use of ciub . 10b 11 Section 501 organizations. Enter: a Gross income from members or shareholders . . . . . . . . . . . . . . . 11a 113 Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them11;; 12a Section non-exempt charitabie trusts. is the organization Form 990 in of Form 1041? 12a If "Yes," enter the amount of tax--exempt interest received or accrued during the year . . 1213 13 Section 501 qualified nonprofit health insurance issuers. a is the organization iicensed to issue qualified health pians in more than one state'I3a Note. See the instructions for additionai information the organization must report on Scheduie O. Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health pians . . . . . . . . . . 13b Enterthe amount of reserves on hand . . . . . . . . . . . . . . . . . 13?; 143 Did the organization receive any payments for indoor tanning services during the tax year"Yes," has it filed a Form 720 to report these payments? if "No, provide an explanation in Scneduie . 14b Form 990 (2011) 6:33:38 PM 5 Form see (2011) Page 6 Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b beiow, and for a "No" response to line 8a, 8b, or 'lOb below, describe the circumstances, processes, or changes in Schedule 0. See instructions. Check if Schedule 0 contains a response to any question in this Partvl . . . . . . . . . . . . . . Section A. Governing Body and Management Yes No 'ta Enter the number of voting members of the governing body at the end of the tax year. . 'ta 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. I Enter the number of voting members included in line 1a, above, who are independent . 1b 2 Did any officer, director, trustee, or key employee have a family relationship or a business reiationship with any other officer, director,-trustee, or key employeeDid the organization deiegate control over management duties customarily performed by or under the direct supervision of officers, directors, or trustees, or key emptoyees 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 organizations assets? . 6 7 Did the organization have members or stockhoidersDid the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing bodyAre any governance decisions of the organization reserved to (or subject to approve! by) members, stockholders, or persons other than the governing bodyDid the organization contemporaneousiy document the meetings held or written actions undertaken during the year by the following: a ThegoverningbodyEach committee with authority to act on behalf of the governing bodythere any officer, director, trustee, or key empioyee listed in Part Vii, Section A, who cannot be reached at 7a the organization's mailing address'? if "Yes, provide the names and addresses in Schedule Section B. Policies his Section requests information about policies not required by the Internal Revenue Code.) Yes No me Did the organization have locai chapters, branches, or affiliates? . . 10a 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 organizations exempt purposes? tta Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? Describe in-Scheduie the process, if any, used by the organization to review this Form 990. 12a Did the organization have a written confiict of interest poiicy? if "No, go to iine 112a Were officers, directors, or trustees, and key empioyees required to disclose annually interests that could give rise to conflicts? 121;; 0 Did the organization reguiariy and consistently monitor and enforce compliance with the poiicy? it "Yes," describe in Scheduie 0 how this was done . . . . . . . . . . . . . . . . . . . . . . 12? 13 Did the organization have a written whistleblower policyDid the organization have a written document retention and destruction policy'? . . 14 15 Did the process for determining compensation of the following persons inciude a review and approvai by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? The organization's CEO, Executive Director, or top management official . . . . . . . . . . . . 15a Other officers or key employees of the organization . . . . . . . . . . . . . . . . . . . 15b 1/ it to line 15a or 15b, describe the process in Schedule (see instructions). 16a Did the organization invest in, contribute assets to, or participate in a ioint venture or similar arrangement with a taxabte entity during the yeardid the organization foilow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under appiicable federal tax iaw, and take steps to safeguard the organization's exempt status-with respect to such arrangements-1513 Section 0. Disclosure 17 List the states with which a copy of this Form 990 is required to be filed a IN 18 Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and (Section 501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply. Own website Another's website Upon request 19 Describe in Schedule 0 whether (and if so, how), the organization made its governing documents, conflict of interest poiicy, and financiai statements availabie to the public during the tax year. 20 State the name, physical address, and telephone number of the person who possesses the books and records of the Organizatiflni STEPHEN HOURIGAN, ONE NORTH AVE, IN 48204, FAX: (317)454-1387 Form 9.90 (2011) 1'1i14i2012 6:33:38 PM 6 Form 990 (2011) Page 7 Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and independent Contractors Check it Schedule 0 contains a response to any question in this Part VII . . . . . . . . . . . . . . Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 'la Complete this tabie for all persons required to be listed. Report compensation for the calendar year ending with or within the organizations tax year. - 9 List all of the organizations current officers, directors, trustees (whether individuals or organizations), regardless of amount of compensation. Enter -0- in coiurnns (D), (E), and (F) if no compensation was paid. 6 List all of the organization's current key empioyees, it any. See instructions for definition of "key employee." 6* List the organization's five current highest compensated employees (other than an officer, director, trustee, or key empioyee) who received reportable compensation (Box 5 of Form and/or Box 7 _of Form of more than $100,000 from the organization and any related organizations. 6 List all of the organizations former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations. 0 List ail of the organization's former directors or trusteesthat 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 organization nor any related organization compensated any current officer, director, or trustee. Position IE) {do not check more than one (F) Name and Title Average ban "mess person is both an Fieportabie Reportable Estimated hours per Officer and a director/trustee} compensation compensation from amount of week I from related other {describe gco 3,3' 9 the organizations Compensation hours for 3-3 3 organization from the related El 5 3" .3 3' organization organizations 9 5:3" 3 and related in Schedule organizations 0} 9+ 5 it D. .- DIRECTOR AND CHAIRMAN 1 32,083 0 0 -- DERECTOR 1 0 0 0 . DIRECTOR 1 i/ 0 0 GLENN DIRECTOR 1 v' 0 0 0 PH-fl DIRECTOR 0 0 (6) ROBERT MYER 82,?82 0 63,197 LINDA CFO 50 65,169 0 10,000 519.} -- -- -- (13) 4) Form 990 (2011) 1111412012 6:33:38 PM 7 Form 990 (2011) Page 8 Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (0) {do not than one (E) Name and title Average b0x_ "mess person is both an Fleportable Reportable Estimated hours per offgceyandadirector/imsteei compensation compensation from amount of week 0 3: _n from related other {describe 3 3:3 9, the organizations compensation hours for 8 to 3 organization irornihe related 31%" 5 organization organizations -1 and related in Schedule fa at 'gt organizations 0} 3 E3 5 O. .llE'_l (18) (20) ?21) (24) 'lb Sub--tota180.034 0 73,19? Total from continuation sheets to Part VII, Section A 0 0 0 cl Total (add lineslb . . . . . . . . . a 180,034 0 73,19? 2 Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization a 0 Yes No 3 Did the organization iist any former officer, director, or trustee, key employee, or highest compensated employee on line la'? ll "Yes," complete Schedule for such individual . . . . . 4 For any individual listed on line 'la, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? lf "Yes, complete Schedule for such individual. 5 Did any person listed on line la receive or accrue compensation from any unrelated organization or individual for services re_ndered to the organization? ll' "Yes," complete Schedule for such person Section El. independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax yeah . (Bl Name and business address Description of services (C) Compensation 2 Total number of independent contractors [including but not limited to those listed above) who received more than $100,000 of compensation from the organization 0 6:33:38 PM 8 Form 990 (2011) Form 990 (2011) Statement of Revenue Page 9 {Al Total revenue Related or exern pt function revenue {Ci Unrelated business revenue Revenue I exciuded from tax underseofions 512. 513. or 51 a lo 1' Contributions, Gifts, Grants and Other Similar Amounts to Federated campaigns. . . 1a lviembershipdues . . . . 'lb Funciraising events. . . . to Related organizations. . . 'id Government grants (contributions) 1e Ail other contributions, gifts, grants, and similar amounts not included above 'If Noncasli contributions included in lines ia-ii: Total. Add tines is-11' . 225.000 2a Program Service Revenue (Q ED 0. IEDC STATE CONTRACTS Business Code 900000 1,353,195 1,353,195 900000 90,571 90,571 Ali other program service revenue . Totai. Add lines 2a-21' . 0 1,443,766 Ba 0 7a 8a other Revenue Investment income (inciuding dividends, interest, and other simiiar amounts) income from investment of tax--exempt bond proceeds Royaities 418 418 0 0 '(ii near {ii} Personal Gross rents Less: rental expenses Rental income or (loss) 0 0 Net rentai income or loss) Gross amount from sales of (ii Securities 1 {ii} other assets other than inventory Less: cost or other basis and sates expenses . Gain or (loss) . . 0 Net gain or (loss) Gross income from iunclraising events (not including of contributions reporiedwonnlinentucujj See Partiv, line Less: direct expenses . . . . in Net income or (loss) from funciraising Gross income from gaming activities. See Part iv, iine Less: direct expenses . . . . Net income or (loss) from gaming aoti Gross sales of inventory, less returns and ailowanoes . . . 3 Less: cost of goods sold . . . events . vities . . Net income or (loss) from sales of inventory . . Miscellaneous Revenue Business Code 11a 12 Ali other revenue . Total. Add lines 1ia--i1d . Total revenue. See instructions. VV 1,669,184 1 ,443.766 418 1111412012 6:33:38 PM Form 990 (2011) Form 990 (2011) Statement of Functional Expenses Page 10 Section 501(c)(3) and 501(c)(4) organizations must compiete columns. other organizations must compiete column (A) but are not required to complete coiumns (B), (C), and (D). Check if Schedule 0 contains a response to any question in this Part IX Cl Do not inciude amounts reported on lines 6bPart (A) Total expenses Program service expenses (0) Management and general ex enses tundraising ex enses 1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 0 2 Grants and other assistance to inciividuais in the United States. See Part iv, line 22 . 0 3 Grants and other assistance to governments, organizations, and individuais outside the United States. See Part 1V, lines 15 and 16 . 0 4- Benefits paid to or for members . . . . 0 5 Compensation of current officers, directors," Trustees. and K851 emPi0Vee8 - - 253,231 131477 ?5,284 40,470 6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and - persons described in section 0 7 Other salaries and wages . . . . 39?,160 270,520 81 ,413 45,227 8 Pension plan accruais and contributions (include section 401(k) and 403(b} employer contributions) 0 9 Other employee benefits . 34,411 21,820 8,931 3,660 10 Payroll taxes . . . . . 39.091 28,282 5,231 11 Fees for services a Management 0 Legal 81,382 75,711 5,871 (2 Accounting 4,325 4,325 a Professional tundraising services. See Part IV, line 1? 1' investment management fees Other . . . . -13,898 35,104 12,594 12 Advertising and promotion 96? 967 13 Office expenses 23,192 18,564 4,56? 2,061 14 information technoiogy 1,332 1,332 15' Royalties . 0 16 Occupancy 9,380 4,690 3,12? 1,563 17 Travel . . . . . . . . . . 25,89? 15,559 6,983 3,155 18 Payments of travei or entertainment expenses for any federal, state, or local public otficiais 0 19 Conferences, conventions, and meetings 0 20 interest . . . 0 21 Payments to affiliates . . . . 0 22 Depreciation, depletion, and amortization 325 325 23 Insurance . . . . . . . . . . 24 Other expenses. itemize expenses not covered above. (List miscellaneous expenses in iine 24s. it i tine 24e amount exceeds 10% of line 25, coiumn (A) amount, iistiine 24e expenses on Scheduie O.) - a AND MEMBERSHIP FEES 1,845 1,845 GIFTS 255 255 (3 OTHER EXPENSES 689 689 0 Ail other expenses 0 0 0 0 25 Total functional expenses. Add lines 1 through 24s 921 ,065 609,225 210,473 101,367 25 Joint costs. Compiete this line only if the organization reported in column (B) joint costs from a combined educationai campaign and fundraisin solicitation. Check here it following OP 98--2 (A80 958-720) . . . . 0 Form 99D{2o11} 10 'l1i"i4i2012 6:33:38 PM rm 990 (2011) I $339911 Balance Sheet (A1 is) Beginning of year End of year 1 Cashmnon~interest--bearing . 1 19,125 2 Savings and temporary cash investments . 2 591,418 3 Piedges and grants receivable, net 3 78,000 4 Accounts receivable266,634 5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Comptete Part II of Schedule . . . . . 6 Receivables from other disqualified persons (as defined under section 4958(t)(1)), persons described in section and contributing employers and sponsoring organizations of section 501(c)(9) voiuntary 3 employees' beneficiary organizations (see instructions) 5 7 Notes and loans receivabie, net 7 8 inventories for saie Prepaid expenses and deferred charges 9 8,000 10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule 103 3,308 Less: accumulated depreciation . . . . 10b 325 10:: 3,481 11 traded securities . . . . . . . . . . 11 12 Investments--other securities. See Part IV, line See Part iv, line intangible assets . . . . . . . . . . . . . . . . . . 14 15 Other assets. See Part iv, line 4,583 16 Total assets. Add lines 1 through 15 (must equal line 34969.241 17 Accounts payabie and accrued expenses . . . . . . . . . . 17 219,122 18 Grants payable . 19 Deferred revenue . 20 bond liabilities . . . . . . . . . . . . . 21 Escrow or custodiai account liability. Cornpiete Part IV of Schedule . 3 22 Payables to current and former officers, directors, trustees, key employees, highest compensated empioyees, and disqualified persons. lg Complete Part ll of Schedule . . . . . . . . 13 23 Secured mortgages and notes payable to unrelated third parties 24 Unsecured notes and loans payable to unrelated third parties 25 Other {inciuding federal income tax, payables to related third parties, and other liabilities not included on tines Complete Part 2,000 otScheduieD . . . . . . . . . . . . . . . . . . 25 26 Total liabilities. Add lines 'i7 through Organizations that follow SFAS 11?, check here and complete lines 27 through 29, and lines 33 and 34. 2? Unrestricted net assets . . . . . . . . . . . . . . . . 27 545,109 28 Temporarily restricted net assets . . . . . . . . . . . . . 28 203,010 29 Permanently restricted net assets . . . . . . . . . . . . . Organizations that do not follow SFAS 117, check here a and complete lines 30 through 34. 30 Capital stock or trust principal, or current funds . . . . . 31 Paid~in or capital surplus, or land, building, or equipment fund 32' Fietained earnings, endowment, accumuiated income, or other funds . 33 Totai net assets or fund balances . . . . . . . . . . . . 0 33 748,119 34 Totai and net assetsffund balances . . . . . . . . . 0 34 969,241 Form 990 (2011) Net Assets or Fund Balances 1131412012 6:33:38 PM 11 -Form 990 (2011) Page 12 Reconciliation of Net Assets Check if Schedule 0 contains a response to any question in this Part Xi l:l 1 Total revenue (must equat Part Vllt, column (A), iine 12) . 1 1,889,184 2 Totai expenses (must equal Part IX, coiumn (A), line 25) 2 921,065 3 Revenue less expenses. Subtract fine 2 from line 748,119 4 Net assets or fund balances at beginning of year (must equal Part X, line 38, cotumn (Al) . 4 0 5 Other changes in net assets or fund balances (exptain in Schedule Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equat Part X, line 33, column . . . . . . . '5 743319 Financial Statements and Reporting Check if Schedule 0 contains a response to any question in this Part . '(as No 2a 3a Accounting method used to prepare the Form 990: Cash Accruai El Other Mm 'It the organization changed its method of accounting from a prior year or checked "Other," explain in Schedule 0. Were the organizations financial statements compited or reviewed by an independent accountant? . Were the organization's financial statements audited by an independent accountant"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 seiection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule C). If "Yes" to line 2a or 2b, check a box below to indicatewhether the financial statements for the year were issued on a separate basis, consolidated basis, or both: [3 Separate basis Consolidated basis Both consolidated and separate basis As a resuit 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 . . . . . . . . . . . . . . . . . it "Yes," did the organization undergo the required audit or audits? if the organization did not undergo the required audit or audits, expiain why in Scheduie and describe any steps taken to undergo such audits 2b$/ 3a t/ 3b 6:33:38 PM 12 Form 990 (2011) SCHEDULE A OMB No. 154543047 ?2(C)tt (Form 990 0,990.52, Pubiic Charity Status and Ptihiic Support Complete if the organization is a section 501(c)(3) organization or a section nonexempt charitable trust. Department of the Treasury (mama; Revenue service it>> Attach to Form 990 or Form See separate instructions. Name of the organization Empioyer identification number ELEVATE VENTURES INC. 2?-4118692 Reason for Pubiic Charity Status (Ail organizations must complete this part.) See instructions. The organization is not a private foundation because it is: (For lines through ii, 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 hospitai or a cooperative hospital service organization described in section 4 A medical research organization operated in conjunction with a hospitai described in section Enter the hospitai's name, city, and state: 5 An organization operated for the a coliege or university lonvvuned or operated by a governmental unit described section (Compiete Part ii.) 6 A federai, state, or iocal government or governmental unit described in section 7 An organization that normaiiy receives a substantial part of its support from a governmental unit or from the generai public described in section (Complete Part II.) 8 A community trust described in section (Complete Part Ii.) 9 An organization that normally receives: (1) more than 33'f:s% of its support from contributions, membership fees, and gross receipts from activities related to its exempt iunctions--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 80, 1975. See section 509(a)(2). (Compiete Part '10 [3 An organization organized and operated exclusiveiy to test for pubiic safety. See section 509(a)(4). l:iAn organization organized and operated exclusiveiy for the benefit of, to perform the functions of, or to carry out the purposes of one or more publiciy supported organizations described in section or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and compiete lines through 'iih. a Type I Type ll Type integrated Type |il~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)(i) or section 509(a)(2). If the organization received a written determination from the iFiS that it is a Type E, Type il. or Type Ili supporting organization, check this box . . . . . . . . . . . . . . . . . . . . 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 Yes No below, the governing body of the supported organization119;); (ii) A family member of a person described in above11g(ii) A 35% controlled entity of a person described in or (ii) aboveProvide the following information about the supported organization(s). Name oi' supported (ii) EIN Type of organization (iv) is the organization {vi Did you notify {vi} is the (vii) Amount of organization (described on lines 1--9 in (ii lisiftd 5" We Uiganiz?ltifln in organization in col. support agave or mg; section governing document? col. of your organized in the (see instructions(A) (B) (C) (D) (E) Total 0 For Paperwork Reduction Act Notice, see the instructions for Cat. No. 11285F Schedule A (Form 990 or 990-E2) 2011 Form 990 or . 11l'14!2012 6:33:38 PM . 13 Version A, cycle 1 A (Form 990 or 990-52) 2011 Page 2 Support Schedule for Organizations Described in Sections and (Complete oniy it you checked the box on line 5, 7, or 8 of Part or if the organization taiied to qualify under Part if the organization faiis to quaiify under the tests listed beiovv, please complete Part ill.) Section A. Public Support Calendar year (or fiscal year beginning in) 200?' 2008 2009 2010 2011 (ii Total 1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusuai grants. . . . 225,000 225930 2 Tax revenues levied for the organizations benefit and either paid to or expended on its behalf . . . 0 3 The value of services or facilities furnished by a governmental unit to the organization without charge . . . . 0 Totai. Add lines 1 through 225,000 225,000 5 The portion of total contributions by each person (other than a governmental unit or publiciy supported organization) inciuded on line 1 that exceeds 2% of the amount shown on line 11, coiumn . 225.000 6 Public support. Subtract line 5 from iine 4. Section B. Total Support Calendar year (or fiscal year beginning in) 200? 2008 2009 2010 2011 Totai 7 Amounts from tine 225.000 225.000 8 Gross income from interest, dividends, payments received on securities ioans, rents, royaities and income from similar sources . . . . . . . . 413 413' 9 Net income from unrelated business activities, whether or not the business is reguiariy carried Other income. Do not inciude gain or -ioss from the saie of capital assets (Explain in Part IVTotal support. Add lines 7 through 10 225,418 1.2 Gross receipts from related activities, etc. (see instructions1,443,766 13 First five years. if the Form 990 is for the organizations first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here . . . . . . . . . . . . . . . . . . . . . . a Section C. Computation of Public Support Percentage 14 Public support percentage for 2011 (line 6, column divided by line 11, column . . . . 14 15 Public support percentage from 2010 Schedule A, Part ii, line '15 16a 331/30/0 support test--2011. if the organization did not check the box on line 13, and line 14 is 33'rs% or more, check this box and stop here. The organization quaiifies as a publicly supported organization . . . . . . . . . . . 33ira% support if the organization did not check a box on iine 13 or 16a, and tine 15 is 33'r3% or more, check this box and stop here. The organization quaiifies as a pubiicly supported organization . . . . . . . We test-2011. If the organization did not check a box on line 13, 18a, or 16b, and iine 14 is 1-0% or more, and if the organization meets the "tacts--and~circurnstances" test, check this box and stop here. Expiain in Part IV how the organization meets the "facts--and--circumstances" test. The organization qualifies as a publicly supported a test--2010. if the organization did not check a box on iine 13, 16a, 16b, or We, and iine 15 is 10% or more, and if the organization meets the "facts--and--circumstances" test, check this box and stop here. Expiain in Part IV how the organization meets the "facts~and-circumstances" test. The organization quaiifies as a publicly supported organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 1?b, check this box and see instructions . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . Scheciuie A {Form 990 or 2011 'i1!14i2D12 8:33:38 PM 14 Schedule A (Form 990 or 990-521 2011 Page 3 Support Schedule for Organizations Described in Section (Complete only if you checked the box on line 9 of Part or if the organization failed to qualify under Part ll. If the organization fails to qualify under the tests listed below, ptease complete Part ll.) Section A. Public Support Calendar year (or fiscal year beginning in) 2007 2008 2009 (cl) 2010 2011 it) Total 1 Gifts, grants, contributions, and membership fees received. (00 not include any "unusual grants") 2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organizations tax-exempt purpose . 3 Gross receipts from activities 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 furnished by a governmental unit to the organization without charge . 6 Total. Add lines 1 through 5 . 73 Amounts included on lines 1, 2, and 3 received from disqualified persons 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 Add lines Public support {Subtract line 7c from line 6Section I3. Total Support Calendar year (or fiscal year beginning in) 9 200? 2008 2009 2010 2011 (T) Total 9 Amounts from line 6 . . . 10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources . Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975 . Add lines we and 10b . 1'1 Net income from unrelated business activities not included in tine 10b, whether or not the business is regularly carried on 12 Other income. Do not include gain or loss from the sale of capitai assets {Explain in Part ivTotal support. (Add lines 9, 10c, 11, and 12First 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 divided byline 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 (|ine10c, column (1) divided by line 13, column . . . 17 18 investment income percentage from 2010 Schedule A, Part ill, line 19a 33lra% support if the organization did not check the box on line 14, and line 15 is more than and line 17 is not more than 33'rs%, check this box and stop here. The organization qualifies as a publicly supported organization . 33113'/o support tests-2010; If the organization did not check a box on tine 14 or line 19a, and line 16 is more than 33'rs%, and line 18 is not more than 33'r3%, check this box and stop here. The organization qualifies as a publicly supported organization 20 Private foundation. if the organization did not check a box on tine 14, 19a, or 19b, check this box and see instructions I Scheduie A {Form 990 or 990-52} 2011 6:33:38 PM '15 SCHEDULE OMB (Form 999} Supplemental Financial Statements a Complete if the organization answered to Form 990, Depanmem Oflhe Treasuw Part IV, line 6, 7, 8, 9, 10, 'mama; Revenue Service Attach to Form 990. See separate instructions. Name of the organization Employer identificat ELEEVATE VENTURES INC. 2741 18692 . Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6. Donor advised funds {in} Funds and other accounts '1 Total number at end of year . . . . . 2 Aggregate contributions to (during yea . 3 Aggregate grants from (during year) 4- Aggregate value at end of year . . . . 5 Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organizations property, sublect to the organizations exclusive legal controlDid 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 impermissible private benefitConservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7. 1 Purposelsl of conservation easements held by the organization (check all that apply). Preservation of land for pubiic use recreation or education} [3 Preservation of an historicaily important land area Cl Protection of natural habitat Preservation of a certified historic structure Cl Preservation of open space 2 Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year. Held at the End of the Tax Year Total numberofconservationeasements . .. . . . . . . . . . . . . . . . 2a a Total acreage restricted by conservation easementsNumber of conservation easements on a certified historic structure included in . . . . 2c Number of conservation easements included in (C) acquired after 8/17/06, and not on a historic structure listed in the National Register . . . . . . . . 2d 3 Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the tax year a Number of states where property subject to conservation easement is located a 5 Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holdsStaff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year 7 Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year a 8 easement reported on line 2(cl) above satisfy the requirements of section and section . . . . . . . . . . . . . . . . . . . . . . . . . . yes No 9 in Part Xiv, 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 organizations financial statements that describes the organization's accounting for conservation easements. Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets. Complete if the organization answered "Yes" to Form 990, Part lV, line 8. 'la if the organization elected, as permitted under SPAS 116 (A80 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 XIV, the text of the footnote to its financial statements that describes these items. in If the organization elected, as permitted under SPAS 116 (A80 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: Revenues included in Form 990, Part |ine(ii) Assets included in Form 990, Partx . . . . . . . . . . . . . . . . 2 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: a Revenues included in Form 990, Part iine Assets included in Form 990, Part . . . . . . . . . . . . . . . . . . . . . 9* For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 522830 Schedule 13 (Form 990) 2011 6:33:38 PM 22 Schedule {Form 990) 2011 Page 2 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 toilowing that are a significant use otits collection items (check all that apply): a Public exhibition Loan or exchange programs Scholarly research Other Preservation for future generations 4 Provide a description of the organizations collections and explain how they further the organization's exempt purpose in Part XIV. 5 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 organizatiorrs collection? . . yes No Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990, Part EV, line 9, or reported an amount on Form 990, Part X, line 21. 1a is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not includedonForm99D,PartX"Yes," explain the arrangement in Part Xiv and complete the following table: Amount Beginning balance . Additions during the year Distributions during the year . . . . . . . . . . . . DYesl:l No "Yes," explain the arrangement in 'Part Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part line 10. Current year lb} Prior year Two years back Three years back Four years back 1a Beginning of year balance Contributions . . . . Net investment earnings, gains, and losses . . . Grants or scholarships . Other expenditures for facilities and programs . . Administrative expenses . End of year balance . . . . . 2 Provide the estimated percentage of the current year end balance (line tg, column held as: a Board designated or quasi~endowment er Permanent endowment Temporarily restricted endowment The percentages in 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: (E) unrelated organizations . (ii) related organizations . . . . . . . . . . . . . . . . . if "Yes" to 3a(ii), are the related organizations listed as required on Schedule 4 Describe in Part XIV the intended uses of the organization's endowment funds. Land, Buildings, and Equipment. See Form 990, Part X, line "10. Description of properly Cost or other basis {in} Cost or other basis {cl Accumulated id} Book value (investment) {other} depreciation ta Land . . . . . . . . 0 in Buildings . . . . . . . . . . 0 Leasehold improvements . . . . 0 Equipment . . . . . . . . . 3,806 325 3,481 Other . . . . . . . . . . . 0 Total. Add lines 1a through 1e. {Column must equal Form 990, Part X, column line . . . . 3,481 Schedule {Form 990] 2011 'l'll14i'2fl'l2S:33:38 PM . 23 Schedule [3 (Form 990) 2011 Page 3 lnvestmentsw-Other Securities. See Form 990, Part X, line 12. {bl Book value (cl ltfiethod of valuation: Cost or end--of~year market value Description of security or category {including name of security} (1) Financial derivatives . (2) Closely-held equity interests . line 12. Related. See Form 990, Part {bi Book value Form Pan' col. Description of investment type Method ofvaluation: Cost or end ~of~year market value 1 Total. (Column {bi must equal Form 990, Part X, col. (8) line 13.} Other Assets. See Form 990, Part X, line 15. Description (bi Book vaiue 1 Total. (Column (5) must Form 990, Part X, col. (8) line 15.) . Other See Form 990, Part X, line 25. {la} Book value 1. Description of liabitity (1) Federal income taxes (2) OTHER CURRENT (3) (4) (5) (5) (7) (8) (9) (10) (11) Total. {Column (in) must equal Form 990, Fan' X, col. (B) the 25.) 2,000 2. FIN 48 (A80 740) Footnote. In Part XIV. provide the text of the footnote to the organizations financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Schedule 13 {Form 990} 2011 11i'i4i'2fl12 6:33:38 PM 24 Schedule (Form 990) 2011 Page 4 Reconciliation of Change in Net Assets from Form 990 to Audited Financiai Statements Totat revenue (Form 990', Part Vilt, column (A), line 121,669,184 Totaf expenses (Form 990, Part IX, column (A), line 25) . 921,065 Excess or (deficit) for the year. Subtract tine 2 from line 748,119 Net unreaiized gains (losses) on investments Donated services and use of _facilities Investment expenses . Prior penod adjustments . . . Other (Describe in Part XIVTotai adjustments (net). Add tines 4 through Excess or (deficit) for the year per audited financial statements. Combine Iines ?48,it9 of Revenue per Audited Financiat Statements With Revenue per Return 1 Total revenue, gains, and other support per audited financiai statements . . . . . . . . 1 1,669,184 2 Amounts included on line 1 but not on Form 990, Part tine 12: - Net unreaiized gains on investments . . . . . . . . . . . . 2a Donated serv?ces and use of facilities . . . . . . . . . . . 2b Recoveries of prior year grants . . . . . . . . . . . . . . - 2c Other (Describe in Part XIVAdd lines 2a through 2d . 3 Subtract line 2e from iinei . . . . . . . . . . . 4 Amounts included on Form 990, Part line 12, but not on line 1 a investment expenses not included on Form 990, Part line 7b . . 4a Other (Describe in Part XIVTotal revenue. Add lines 3 and -40. (This must equai Form 990, Part i, iine 721,669,184 of Expenses per Audited Financiai Statements With Expenses per Return 1 Total expenses and tosses per audited financial statements . . . . . . . . . . . . . 1 921,065 2 Amounts inciuded on line 1 but not on Form 990, Part IX, line 25: Donated services and use of facilities . . . . . . . . . . . 2a Prior year adjustments . . . . . . . . . . . . . . . . 2b OtherlossesOther (Describe in Part XEVAdd lines 2a through 2d . 3 Subtract line 2e from iinet . . . . . . . . . . 4 Amounts included on Form 990, Part IX, line 25, but not on line 1: a investment expenses not included on Form 990, Part Vii}, line 7b . . 4a Other (Describe in Part XIV4-13 Add Iines Totai expenses. Add lines 3 and ttc. (This must' equai Form 990, Part I, line 18.) . ,1 Supplemental information - Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part EH, lines ia and 4; Part IV, lines 'lb and 2b; Part V, line 4; Part X, line 2; Part XI, Iine 8; Part XII, lines 2d and 4b; and Part tines 2d and 4b. Also complete this part to provide any additional information. SEE NEXT PAGE 0 1,669,184 0 921,085 0 921,085 Schedule {Form 990) 2011 6:33:38 PM 25 . Supplemental information CompIete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part lines Ia and Part IV, Iines Ib and 2b; Part V, line 4; Part X, line 2; Part XI, line 8; Part XII, fines 2d and 4b; and Part iines 2d and 4b. Also complete this part to provide any additional information. Return Reference Identifier Explanation SCHEDULE PART x. 48 (A80 740) THE INTERNAL REVENUE SERVICE HAS THAT ELEVATE IS A ORGANIZATION AS oeeamso IN LINE 2 I-OOTNOTI-I SECTION 501(c)(3) OF THE swrenmm. RE-IVENUE CODE mo IS EXEMPT FROM FEDERAL mcomss TAXES om REIATED INCOME. ELEVATE IS NOT CONSIDERED TO BE A PRIVATE FOUNDATION. CURRENT ACCOUNTING STANDARDS REQUIRE TO RECOGNIZE A TAX LIABILITY ONLY IF IT IS THAN THAT THE TAX POSITION WOULD BE SUSTAINED IN ATAX EXAMINATION, WITH A TAX EXAMINATION BEING PRESUMIED TO OCCUR. THE AMOUNT RECOGNIZED IS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS GREATER TI-IAN 50% LIKELY OF BIEING REALIZED ON EXAMINATION. FOR TAX POSITIONS NOT MEETING THE LIKELY THAN TEST, NO TAX BENEFIT WILL BE RECORDED. FOR THE YEAR ENDED DECEMBER 31, 2011, MANAGEMENT HAS DETERMINED ELEVATE DOES NOT HAVE ANXTEARXEPOEITIONS THAT RESULT IN ANY UNCERTAINTIES REGARDING THE POSSIBLE IMPACT ON TI-IEIR FINANCIAL -N . ELEVATE DOES NOT EXPECT THE TOTAL AMOUNT OF UNRECOGNIZED TAX BENEFITS TO CHANGE IN THE NEXT MONTHS. RIECOGNIZES INTEREST ANOIOR PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE. ELEVATE DID NOT HAVE ANY AMOUNTS ACCRUED FOR INTEREST AND PENALTIES AT DECEMBER 31, 2011. 6:33:38 PM 26 Name ofthe organization SCHEDULE Transactions With interested Persons 9 OMB N0-15450047 990 01' 990-52) Is>> Complete if the organization answered "Yes" on Form 990, Part IV, line 25a, 25b, 26, 27, 238, 28b, or 280, Department ofthe Treasury or Form 990-52, Part V, line 38a or 4013. lfiternal Revenue Service Attach to Form 990 or Form 990--EZ. See separate instructions. Employer identification number ELEVATE VENTURES INC. 27-4118692 Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only). Compiete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 4013. Corrected? Name of disqualified person Description of transaction Yes No 2 Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958Enter the amount of tax, if any, on line 2, above, reimbursed by the organization . . . . . . . . 9 Loans to andfor From interested Persons. Complete if the organization answered "Yes" on Form 990, Part IV, iine 26, or Form 990--EZ, Part V, tine 38a. Name of interested person and purpose (bl Loan to or lrom Original Balance due in default? if} Written the organization? principal amount - by board Of agreement? committee? To From Yes No Yes No Yes No e$ Grants or Assistance Benefiting Interested Persons. Compiete if the organization answered "Yes" on Form 990, Part IV, line 27. Name of interested person (13) Relationship between interested person and the Amount and type of assistance organization 10 For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990--EZ. Cat. No. 5005623. Schedule [Form 990 or 2011 6:33:38 PM i 27 Soheduie (Form 990 or 990--EZ) 2011 Page 2 Business Transactions involving interesteci Persons. Complete if the organization answered "Yes" on Form 990, Part N, line 28a, 2813, or 280. Name of interested person Relationship between Amount of Description of transaction Sharing 0? interested person and the transaction organization Yes No 1 SEE STATEMENT 3 4 Suppiementai information Complete this part to provide additionai information for responses to questions on Soheduie (see instructions). Schedule 1. {Form sec or 2011 1111412012 6:33:38 PM 28 Business Transactions involving interested Persons (continued) Name of interested person Retatienship between Amount Description of Sharing interested person and the of transaction transaction of organization organization's . revenues? Yes No CONSULTING SERWCES BATES THE 32,083 PROWDED TO ORGANIZATSON 11H #2012 6:33:38 PM 29 Schedule 0 Form 990) epanment of Treasury Internal Revenue Service Supplemental Information to Form 990 or OMB No. 1545-0047 Compiete lo provide information for responses to specific questions on Forn1990 or 990-132 or to provide any ar.idItionaI information. Name of the Organization ELEVATE VENTURES INC. Empioyer Idenlificalion Number Return Reference Identifier Explanation FORM 990, PART LINE 1 ORGANIZATIONS MISSION THE ORGANIZATION WAS FORMED AT THE THE STATE. OF ECONOMIC DEVELOPMENT AGENCY, THE INDIANA ECONOMIC DEVELOPMENT CORPORATION TO MANAGE THE ACTIVITIES OF THE ENTREPRENEURIAL INITIATIVES, INCLUDING THE 21ST CENTURY RESEARCH AND TECHNOLOGY FUND ("21 AND TO ENI-IANCE THE ECONOMIC IMPACT OF THE 21 FUND FOR INDIANA ECONOMICALLY DISTRESSED REGIONS BY ATTRACTING AND DEVELOPING MORE ENTREPRENEURIAL TALENT AND EARLY-STAGE CAPITAL FOR INDIANA ENTREPRENEURS. PRIMARY PURPOSE IS TO STIMULATE ECONOMIC DEVELOPMENT IN THE STATE OF INDIANA BY FOSTERING AND PROMOTING THE DEVELOPMENT OF ENTREPRENEURS AND EMERGING COMPANIES WITHIN THE STATE OF INDIANA IN SUPPORT THE INDIANA ECONOMY AND ITS CREATION AND RETENTION OF JOBS. FORM 990. PART VI, SECTION LINE 118 REVIEW OF FORM 99$} BY GOVERNING BODY THE FORM 990 WAS REVIEWED IN DETAIL BY THE CFO AND CEO. A FINAL DRAFT OF THE FORM 990 WAS VIA EMAIL TO EVERY MEMBER OF THE GOVERNING BODY PRIOR TO FILING WITH THE. IRS. FORM 990. PART VI, SECTION 8. LINE 12C CONFLICT OF INTEREST POLICY EVERY BOARD MEMBER. OFFICER, AND DE-ISIGNATED CONSULTANT IS REQUIRED TO SIGN ANNUALLY A CONFLICT OF INTEREST STATEMENT DISCLOSING POTENTIAL OR ACTUAL CONFLICTS OF INTEREST WITH THE ORGANIZATION. TI-IE COMPLIANCE OFFICER HAS BEEN APPOINTED BY THE BOARD TO REVIEW THE DISCLOSURE STATEMENTS AND MONITOR BOARDICOMMITTEE MEETINGS TO ENSURE THAT ANY MEMBER WITH A POTENTIAL CONFLICT EXCUSE THEMSELVES FROM THE DISCUSSION AND VOTE. THIS MONITORING AND RECLISEMENT PROCESS IS ALSO CONDUCTED, AS NEEDED, WITH ALL EMPLOYEES. AND DESIGNATED CONSULTANTS. FORM 990, PART VI. SECTION B. 15A PROCESS USED TO ESTABLISH COMPENSATION OF TOP MANAGEMENT OFFICIAL A COMPENSATION COMMITTEE WAS APPOINTED TO ESTABLISH COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL. THE COMMITTEE USED COMPARABILITY DATA IN THEIR DETERMINATION TO ENSURE COMPENSATION IS REASONABLE. DISCUSSION AND ANALYSIS OF THE PROCESS WAS DOCUMENTED IN THE COMPENSATION COMMITTEE MINUTES. THE COMPENSATION COMMITTEE PRESENTED TO THE BOARD OF DIRECTORS THEIR RECOMMENDATION FOR COMPENSATION THE BOARD VOTED ON THE COMPENSATION BASED ON THE COMMITTEES RECOMMENDATION. THIS PROCESS WAS LAST ERTAKEN IN 2011. FORM 990. PART VI, COMPENSATION THE CEO HAD THE AUTHORITY HIRE AND TO SET INITIAL COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES. LINE 15B PROCESS FOR OTHER SUBSEOUENT RAISES WERE DETERMINED BY THE COMPENSATION COMMITTEE AND BY THE BOARD OF OFFICERS DIRECTORS. THIS PROCESS WAS LAST UNDERTAKEN IN 2011. FORM S90, PART VI. PROCESS TO THE CEO HAD THE AUTHORITY TO HIRE AND TO SET INITIAL COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES. LINE 15I3 ESTABLISH SUBSEOUENT RAISES WERE DETERMINED BY THE COMPENSATION COMMITTEE AND APPROVED BY THE BOARD OF COMPENSATION OF OTHER OFFICERS DIRECTORS. THIS PROCESS WAS LAST UNDERTAKEEN IN 2011. FORM Q90, PART VI. SECTION C, LINE I9 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC FINANCIAL STATEMENTS. GOVERNING DOCUMENTS. AND CONFLICT OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO INTERNAL REVENUE CODE IIRC) SECTION 6104. THESE DOCUMENTS ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. 6:33:38 PM 30 SCHEDULE I ome No. 1545-Oi)-1? {Fmm 990) Retated Orgamzaizrons and Unretated Partnerships Q0 cfi fl Complete if the organization answered "Ycs" to Form 990. Part IV. tine 33, 34. 35, 36, or Department of the 'ire'4sury . mama! Revenue smlizo 1* Attach to Fonn $390. ifvsec separate instructions. Name of the organization Employer rdenhticatinrber ELEVATE VENTURES INC. 274118692 identification of Disregarded Entities (Compiete if the organization answered "Yes" to Form 990, Part IV. line 33.) ta} lb! -10) id} (8 Name, address, and EIN of disregarded entity Primary activity Legal domicile (state Total income End-oi--year assets Direct controlling or toraign country} entity ELEVATE ADWSORS. LLC (90--D90E3210) GENERAL PARTNER 1 NORTH CAPITOL AVENUE. some 900, EN 45204 es 0 ca VENTURE (51 Identification of Retated Tax~Exempt Organizations {Complete if the organization answered "Yes" to Form 990, Part IV, tine 34 because it had one or more reiated organizations during the tax year.) (hi id} tel {ti Name, address, and EN of related organizzrlion Primary activity Legai domicile {state Exempt Code section Public charity status Direct controtiing 5T2iDii'-3} or foreign country} (if section entity entity? Yes No ._t2i --i3t For Paperwork Reduction Act Notice, see the instructions for Form 9530. Cat. No. 5t)135Y Schedule Ft [Form 990} 2011 5:33:38 PM 31 Soheduie (Form 990} 2011 Page 2 identification of Related Organizations Taxabie as a Partnership (Compiete if the organization answered "Yes" to Form 990, Part IV, tine 34 because it had one or more related organizations treated as a partnership during the tax year.) (hi id} {ii} [ii {kl Md Pt'i""5'Y I Pfedfiminafll Share oi total Share at enct--of-- [kproportianaie Code General or Percentage of domicile entity |F330m9 ('$3305. income year assets atkmations? amount in box 20 of managing ownership reialeci organization (stale or "firemttfidl Schedute K-1 partner? Foreign {F-orm1U55} counw} sections 512-SMIdentification of Ftetatecl Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, tine 34 because it had one or more related organizations treated as a corporation or trust during the tax year.) {hi id} (9) If} Name, address. and EIN of related organization . Primary activity Legal domicile Direct controliing Type of entity Share oi tola! Share of Percentage {state 0: entity corp, 8 corn, inoorne cnd--of--year assets ownersitip foreign coiantiy) or trust) - .. (51 E51 Sciteduie [Form 99512011 11i'i4i2D12 6:33:38 PM 32 Schedule (Form 990} 2011 Page 3 Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part N, line 34, 35, 353, or 36.) Note. Complete line 1 if any entity is listed in Parts Ii, Ill. or of this schedule. 1 During the tax year, did the organization engage in any ofthe toilowing transactions with one or more related organizations listed in Parts Receipt of interest {ii} annuities royalties or {iv} rent from a control ted entity . Gift, grant, or capital contribution to related organlzationfsi Gift, grant, or capitai contribution from related organizationtsl Loans or ioan guarantees to or for related organization(s} Loans or loan guarantees by related organizationlsl . Sale of assets to related organizationtsi . Purchase of assets from retated organization(s) Exchange of assets with related organizationts) . . . Lease of facitities. equipment, or other assets to related organization(s) Lease of facilities. equipment, or other assets from reiated organization(Performance of services or membership or fundraising soticitations for reiated organizationtsl . Performance of services or mernbership or iundraising soticitations by related organizationts} . Sharing of facilities, equipment, mailing lists. or other assets with related organization(s) . Sharing of paid employees with related organization(s) . Reimbursement paid to related organizatlon(s) for expenses Fieimbursernent paid by related organizationtsl for expenses . Other transfer of cash or property to related organization(s} . . . . Other transfer of cash or property from related organizationlsl . . . . . It the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction threshoids. xx xx xg 2 {bl tel id} Name of other organization Transaction Amount involved Method of determining type ta--r] amount irwolved {Ti (31 (53 8:33:38 PM 33 Schedule [Form 990} 2011 Page 4 Schectule a (Form 990} 201-. Unreiateo' Organizations Taxable as a Partnership {Cornpiete if the organization answered "Yes" to Form 990, Part N, line exclusion for certain investment ta} {hi id} tel {hi (11 til {it} Name. address. and EIN of entity Primary activity Legai domicile Predominant alt partners Share of Share of Code General or Percentage [slate or foreign income (rotated, section lotai income end-ot--year amount in box 20 managing ownership country} assets of Schedule K-1 partner'? lrom tax under organizatioiis? {Form 1055) section 512-514Provide the foitowing information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by totai assets or that was not a reiated organization. See instructions Schedule [Form 990} 2811 34 '1 412012 6:33:38 PM Identification of Related Organizations Taxahir: as a Partnership (continued) Name, address and EN of related organizalion {lzu} PrimaIyAc1'wily (cj Legs! Direct Predominant (fl Share of Share of CodeV~ domicile tolal income end-of-year Dispropor UBE amount Genera! Percentage (F-I310 0! forcisrn entity assets lionate in box 20 of or ownership afiecation Schedute K-- managing smbons 512 .11 . I s? partner? Yes No 108") Yes No WDIANA 21ST CENTURY FUND, LP (45- ELEVATE 3126479) INVESTMENT - - 1 NORTH CAPITOL AVENUE, SUITE 900, FUND 95 ""53 ED 0 0 9 "l 46204 6:33:38 PM 35 eppiicatinn fer Extension st Time in Fiie an Exempt Qrganization Return F0 rm {Rem January 2012) OMB N0. 1545-1 709 01' the uh File a separate application for each return. internai Fievenue Service 9 If you are filing for an Automatic 3--ivionth Extension, complete oniy Part I and check this box . . . . . . if you are filing for an.Additionai (Not Automatic) 3--Wionth Extension, complete oniy Part Ii (on page 2 of this form). Do not complete Part ii uniess you have already been granted an automatic 3-month extension on a previously filed Form 8888. Eiectronic filing (e-fiie). You can electronically file Form 8888 it you need a 3-month automatic extension of time to fiie (6 months for a corporation required to file Form 990-7), o'r an additional (not automatic) 8-month extension of time. You can electronically the Form 8888 to request an extension of time to his any of the forms listed in Part 1 or Part li with the exception of Form 8870, Information Return for Transfers Associated With Certain Personal Benefit Contracts, which must be sent to the IRS in paper format (see instructions). For more details on the electronic filing of this form, visit and click on e--fiie for Charities 8 Nonprofits. Automatic 3-Month Extension of Time. Oniy submit original (no copies needed). A corporation required to file Form 990-?" and requesting an automatic 8-month extensionmcheck this box and complete eg At! other corporations (inciuding 1120-0 fliers), partnerships, and trusts must use Form 7004 to request an extension of time to fiie income tax returns. Enter filer's identifying number, see instructions Type or Name of exempt organization or other filer, see instructions. Employer identification number (Em) or print ELEVATE vemuees 27-4118682 File by the Number, street, and room or suite no. if a PO. box, see instructions. Social security number (SSN) due date for ONE NORTH 900 City, town or post office, state, and code. For a foreign address, see instructions. IN 46204 Enter the Return code for the return that this application is for (file a separate application for each returnApplication Return Application Return is For Code is For Code Form 990 01 Form 990-T (corporation) 0? Form 990-BL 02 Form 1041-A 08 Form 990-EZ 01 Form 4720 09 Form 990-PF 04 Form 5227' 10 Form 990--T (sec. 401(a) or 408(a) trust) 05 Form 8069 it Form 990-1" (trust other than above) 08 Form 8870 12 9 The books are in the care of LINDA Teiephone No. a (317)294-9474 FAX No. (317)454-1387 6 it the organization does not have an office or piece of business in the United States, check this box . . . . . . 0 if this is for a Group Return, enter the organizations four digit Group Exemption Number (GEN) . If this is for the whole group, check this box . . . . If it is for part of the group, check this box . . . . and attach a list with the names and Eiivs of all members the extension is for. 1 I request an automatic 8-month (8 months for a_ corporation required to file Form 990-1) extension of time until 28 to file the exempt organization return for the organization named above. The extension is for the organizations return for: caiendar year 20 or tax year beginning and ending 20 2 If the tax year entered in iine 1 is for iess than 12 months, check reason: initiai return Final return Cl Change in accounting period 3a if this application is for Form 990--i3L, 990-PF, .8904", 4720, or 6069, enter the tentative tax, less any nonrefundable credits. See instructions. 33 it this application is for Form 990-PF, 4720, or 6089, enter any refundable credits and estimated tax payments made. Include any prior year overpayment aiiowed as a credit. Balance due. Subtract line 3b from line 3a. inciude your payment with this form, if required, by using (Etectronic Federaif-< ljmand attach a list with the names and EINS of all memb_ers the extension is for. 4 i request an additional 3-month extension of time Until 20 '12 . 5 For caiendar year or other tax year beginning 20 and ending V20 6 It the tax year -entered in line 5 is-for less than. 12 months, check reason: return [3 A I Change in eccountingineriod State in detail why you need the extension Iji_?_ CAN GATHER THE TO A C20iy'i Ptefre: ACCURATE RETURN, .. 83 If this application is for Form 990--t3L, 990--PF, 990-T, 4720, or .8089, enter the tentative tax, less any nonrefundabie credits. See instructions. is if this application is for Form 472{), or 6069, enter any refundabie credits and estimated tax payments made. Include any prior year over'paym'ent- allowed as a' credit and any amount paid previousiy'with Form 8868. Balance due. Subtract tine 8b from line 8a. inctude your payment with this 'form, if required, by using EFTPS [Eieetronic Federal Tax Payment System). See instructions. 8C Signature and Verificaflon must be comiileted for Part only. Under penatties of perjury, I declare that I have examined this form. inciuding accompanying schedutes and s~,taiement3_ and to the best of my knowiedge and belief, it is true, correct. and that i am authorized to prepare this form. Signature? Tltie Dam}, I Form 8868 (Rev. 1-2012) PM 2