Form Schedule F (Form 9 Schedule F (Form 9 Statement of Activities Outside the United States

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SCHEDULE F
(Form 990)

Statement of Activities Outside the United States
▶

Department of the Treasury
Internal Revenue Service

2012

Complete if the organization answered "Yes" to Form 990,
Part IV, line 14b, 15, or 16.
▶

Attach to Form 990.

▶ See

Open to Public
Inspection

separate instructions.

Employer identification number

Name of the organization

Part I

OMB No. 1545-0047

General Information on Activities Outside the United States. Complete if the organization answered “Yes” to

DRAFT AS OF
July 5, 2012
DO NOT FILE
Form 990, Part IV, line 14b.

1

For grantmakers. Does the organization maintain records to substantiate the amount of its grants and other
assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria used to award the
grants or assistance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

2

For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of its grants and other
assistance outside the United States.

3

Activities per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)
(a) Region

(1)
(2)

(b) Number of
offices in the
region

(c) Number of
employees,
agents, and
independent
contractors
in region

(d) Activities conducted in
region (by type) (e.g.,
fundraising, program services,
investments,
grants to recipients
located in the region)

(e) If activity listed in (d) is
a program service,
describe specific type of
service(s) in region

No

(f) Total
expenditures for
and investments
in region

(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
3a Sub-total . . . . . .
b Total from continuation
sheets to Part I . . . .
c

Totals (add lines 3a and 3b)

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

Cat. No. 50082W

Schedule F (Form 990) 2012

Part II
1

(1)
(2)
(3)
(4)
(5)
(6)

DRAFT AS OF
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DO NOT FILE

Page 2
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered “Yes” to Form 990,
Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.

Schedule F (Form 990) 2012

(a) Name of
organization

(b) IRS code
section and EIN
(if applicable)

(c) Region

(d) Purpose of
grant

(e) Amount of
cash grant

(f) Manner of
cash
disbursement

(g) Amount of
non-cash
assistance

(h) Description
of non-cash assistance

(i) Method of
valuation
(book, FMV,
appraisal,
other)

(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
2
3

Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt
by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter . . . . . . . . . . . . ▶
Enter total number of other organizations or entities
. . . . . . . . . . . . . . . . . . . . . . . . . . . ▶
Schedule F (Form 990) 2012

Part III

(a) Type of grant or assistance

(1)
(2)
(3)
(4)
(5)
(6)

DRAFT AS OF
July 5, 2012
DO NOT FILE

Page 3
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 16.
Part III can be duplicated if additional space is needed.

Schedule F (Form 990) 2012

(b) Region

(c) Number of
recipients

(d) Amount of
cash grant

(e) Manner of
cash
disbursement

(f) Amount of
non-cash
assistance

(g) Description
of non-cash assistance

(h) Method of
valuation
(book, FMV,
appraisal,
other)

(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Schedule F (Form 990) 2012

Schedule F (Form 990) 2012

Part IV
1

2

3

4

5

6

Page

4

Foreign Forms

Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If “Yes,”
the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign
Corporation (see Instructions for Form 926) . . . . . . . . . . . . . . . . . . . .

Yes

DRAFT AS OF
July 5, 2012
DO NOT FILE

No

Did the organization have an interest in a foreign trust during the tax year? If “Yes,” the organization
may be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and
Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a
U.S. Owner (see Instructions for Forms 3520 and 3520-A) . . . . . . . . . . . . . . .

Yes

No

Did the organization have an ownership interest in a foreign corporation during the tax year? If “Yes,”
the organization may be required to file Form 5471, Information Return of U.S. Persons With Respect To
Certain Foreign Corporations. (see Instructions for Form 5471) . . . . . . . . . . . . .

Yes

No

Was the organization a direct or indirect shareholder of a passive foreign investment company or a
qualified electing fund during the tax year? If “Yes,” the organization may be required to file Form 8621,
Information Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing
Fund. (see Instructions for Form 8621) . . . . . . . . . . . . . . . . . . . . .

Yes

No

Did the organization have an ownership interest in a foreign partnership during the tax year? If “Yes,”
the organization may be required to file Form 8865, Return of U.S. Persons With Respect To Certain
Foreign Partnerships. (see Instructions for Form 8865) . . . . . . . . . . . . . . . .

Yes

No

Did the organization have any operations in or related to any boycotting countries during the tax year? If
“Yes,” the organization may be required to file Form 5713, International Boycott Report (see Instructions
for Form 5713) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

No

Schedule F (Form 990) 2012

Schedule F (Form 990) 2012

Part V

Page

5

Supplemental Information
Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f)
(accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III
(accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to
provide any additional information (see instructions).

DRAFT AS OF
July 5, 2012
DO NOT FILE

Schedule F (Form 990) 2012